CAMP MEDICAL RECORD

Name of Camper: _____________________________

Age:________
Has camper had any of the following infectious diseases?
Measles: ________

Whooping cough: ________

Mumps: ________

Chicken Pox: ________

Immunization history (dateof last injection):

Tetanus: ________
Diphtheria: ________

Whooping cough: ________

Measles: ________

Smallpox: ________

Polio: ________

Typhoid: ________

Other: ________

Any severe reactions to insect bites or bee stings? __________________

___________________________________________________________
Allergic to penicillin, sulfa or other drug? __________________________
___________________________________________________________
State blood type, if known:
________
remarks: _____________________________________________
___________________________________________________________
___________________________________________________________
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Any severe reactions to insect bites or bee stings? __________________

___________________________________________________________
Allergic to penicillin, sulfa or other drug? __________________________
___________________________________________________________
State blood type, if known:
________
Remarks: _____________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Please state if any of the following conditions are in the medical history:
Allergies:

Asthma: ________

Mastoiditis: ________

Hay Fever: ________

Other ear infection: ________

Hives: ________

Frequent colds or sore throat: ________

Other (state): ________
Enuresis: ________
Boils: ________
Fainting: ________
Somnambulism: ________
Sinus infection: ________

Constipation: ________
Epilepsy: ________
Rheumatic Fever: ________
Diabetes: ________
Bronchitis: ________
Nose bleeding: ________

Convulsions: _________________

Is there any other past or present condition? _______________________

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Has there been any illness during the past few months? ______________
_______________________
____________________________________
Is there any major or minor disability or limitation? __________________
___________________________________________________________
Are any restrictions in camp activities necessary? ___________________
_______________
____________________________________________
Is any special diet or medication necessary? _______________________
___________________________________________________________
Any food sensitivity? _________________________________________