Camp Collins Health History Form

Child’s Name*

1. Had any recent injury, illness or infectious disease?*

YesNo

2. Ever been hospitalized?*

YesNo

3. Ever had a head injury within the last 6 months?*

YesNo

4. Ever been knocked unconscious?*

YesNo

5. Wear glasses, contacts or protective eye wear?*

YesNo

6. Ever passed out during or after exercise?*

YesNo

7. Ever had chest pains during or after exercise?*

YesNo

8. Has high or low blood pressure?*

YesNo

9. Ever been diagnosed with a heart murmur?*

YesNo

10. Ever have back problems?*

YesNo

11. Ever had problems with joints (ex. knees, ankles)?*

YesNo

12. Have an orthodontic appliance at camp?*

YesNo

13. Have any skin problems (ex. itching, rash, acne)?*

YesNo

14. Have mononucleosis in the past 12 months?*

YesNo

15. Had problems with diarrhea/constipation?*

YesNo

16. If female, have an abnormal menstrual history?*

YesNo

17. Have an eating disorder?*

YesNo

18. Any current physical, mental or psychological conditions requiring professional treatment or additional consideration?*

YesNo

Explain “yes” answers and please note the question number*

Name of family physician*

Phone*

Which of the following Diseases has the participant had?

Date of last TB Mantoux test if taken

Date

Result

My child received his/her last Tetanus shot (DTP or Booster) on*

I verify that my child is up-to-date on ALL immunizations required for school.My child is Exempt from immunizations due to Medical, Religious, or other reasons.

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:*

Are there any camp activities from which this participant should be exempt for health reasons? If so, please list. Is there any other information which has an impact upon the participant’s ability to fully participate in our program? If so, please list.*

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.

Date*

Date

I (Camper Name) also understand and agree to abide with any health related restrictions placed on my camp activities.*

Type a question*

Date*

Date

Will your child travel outside the US within 14 days of the start of camp?*

Does your child live in congregate housing (apartments, shelters, condos, transitional housing)?*

Has your child been diagnosed with COVID-19 in the last 90 days?*

If yes, date of your child's diagnosis?*

Date

If yes, was the diagnosis confirmed with a COVID-19 test?*

Has your child had any other illness within the last 6 months?*

Name or type of illness*

Does your child have any other condition that may mimic the symptoms of COVID-19?*

Please explain*

Will your camper be up to date on their COVID-19 vaccine before arrival at camp?*

YMCA of Columbia-Willamette

Health History

Allergies: Please check all that apply to the participant.

Diet:

Chronic Concerns

General health Questions

Immunization Verification—PLEASE FILL OUT COMPLETELY: