Health History and Medical Release

Name Email
Date    
 
Please select giving approximate dates
Illness   Allergies   Diseases
Diabetes Insect Bites Chicken Pox
Convulsions Penicillin Measles
Ear Infections Other Drugs German measles
Asthma Poison Oak Mumps
Back Injury Hay Fever Other

Please give any additional information to those items checked above

Operations or serious illnesses

Chronic or recurring illness

Should any specific activities be restricted?

Do you have any health condition that might require medical attention while at camp, i.e. Diabetes, seizures, allergic reactions, etc.? List

Date of last Tetanus
Date of last TB Test
Date of last Health Exam
 
How would you describe your health? Excellent Good Fair Poor

Are you taking any medications? If yes, please list: