• YMCA of Columbia-Willamette

    YMCA of Columbia-Willamette

    YMCA Camp Collins Health History Form
  • Gender*
  • Birthdate*
     / /

  • Emergency Contact Information (If parent cannot be reached)

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Insurance Information - Is the participant covered by family medical/hospital insurance?*
  • Format: (000) 000-0000.
  • Birthdate of policy holder*
     / /

  • Health History

    The following information must be filled out by the parent/guardian or adult staff member. We use this data to provide healthcare personnel with background information on the camper/staff and to educate counseling staff on camper needs.

  • Allergies: Please check all that apply to the participant.

  • Participant has known allergies,*
  • Causes anaphylaxis?*
  • Causes anaphylaxis?*
  • Causes anaphylaxis?*

  • Diet:

    Please check all those that apply to participant. We can work with some medically prescribed diets but cannot cater to individual food preferences. Contact the Camp Office at 503.663.5813 if you have questions regarding the participant’s diet while at camp.
  • Type a question

  • Chronic Concerns

  • This participant has:*
  • Check all that apply:

  • General health Questions

    Please explain "yes" answers in the space provided below.
  • 1. Had any recent injury, illness or infectious disease?*
  • 2. Ever been hospitalized?*
  • 3. Ever had a head injury within the last 6 months?*
  • 4. Ever been knocked unconscious?*
  • 5. Wear glasses, contacts or protective eye wear?*
  • 6. Ever passed out during or after exercise?*
  • 7. Ever had chest pains during or after exercise?*
  • 8. Has high or low blood pressure?*
  • 9. Ever been diagnosed with a heart murmur?*
  • 10. Ever have back problems?*
  • 11. Ever had problems with joints (ex. knees, ankles)?*
  • 12. Have an orthodontic appliance at camp?*
  • 13. Have any skin problems (ex. itching, rash, acne)?*
  • 14. Have mononucleosis in the past 12 months?*
  • 15. Had problems with diarrhea/constipation?*
  • 16. If female, have an abnormal menstrual history?*
  • 17. Have an eating disorder?*
  • 18. Any current physical, mental or psychological conditions requiring professional treatment or additional consideration?*
  • Format: (000) 000-0000.
  • Which of the following Diseases has the participant had?
  • Date of last TB Mantoux test if taken
     / /

  • Immunization Verification—PLEASE FILL OUT COMPLETELY:

  • *

  • Medications - You will be asked to complete a “Medication Authorization form” on the first day of camp if your child is to take medicationsduring their stay at camp. Medications (both prescription and over-the-counter) will only be accepted and dispensed by the Health Officer if provided in their original container and with current prescription labeling. Please check medication labels and expiration dates prior to your arrival at camp.

  • The following medications, stocked in the Camp Health House, are used to manage illness or injury and dispensed as directed by our medical protocols. Please check the box next to those medications your camper may be given:

  • Please check the box next to those medications your camper may be given:*

  • Parent/Guardian Authorization for Health Care: This health history is correct, and the person described has permission to participate in all camp activities except as noted by me on this form and/or a physician. I attest that all immunizations required for school are up to date. I give permission to the YMCA Camp Collins medical personnel to release any records necessary for insurance purposes and provide or arrange necessary related transportation for myself/my child in the case of a medical emergency. If I cannot be reached in an emergency, I give permission to the physician to secure and administer treatment, including hospitalization, for my child. This completed form may be photocopied. I understand that information about my child’s health may be shared on a “need to know” basis with other camp staff.

  • Clear
  • Date*
     - -
  • Clear
  • Date*
     - -
  • If yes, date of your child's diagnosis?*
     / /
  •  
  • Should be Empty: