STAFF HEALTH HISTORY AND MEDICAL FORM

This form must be returned to the following address by June 1st, 2012.
Camp TEKO Forms - Temple Israel
2324 Emerson Avenue South
Minneapolis, MN 55405
Phone: 612-374-0321
The information on this form is extremely important to ensure the health and safety of all campers and staff.
Please be thorough and candid. No person will be permitted to attend camp until this form is completed.

Participant name______________________________________________________________________
Last

First

Middle

Home address________________________________________________________________________
Street address

Gender: Male Female

City

Birth date_______________

State

Zip

Age at camp_______________

Emergency contact
Name__________________________________
Phone (h)____________________

Relationship to Staff Member__________________

(w)____________________

(c)__________________________

Important These boxes must be completed for attendance.

Insurance Information
In order for Camp TEKO to guarantee medical services should the need arise due to illness or accident, it is
necessary to present the medical service provider with evidence of valid insurance coverage.
PLEASE ATTACH A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD ON A
FULL SHEET OF PAPER.
Insurance company__________________________
Name of insured______________________
Policy #___________________________________
Group #_____________________________
Employer__________________________________
Phone_______________________________
Parent/Guardian Authorizations: This health history is correct and complete as far as I know. The person
herein named has permission to engage in all camp activities except as noted.
I hereby give permission to the camp to provide, seek, and consent to routine health care, administration of
prescribed medications and emergency treatment for my child/me as may be necessary, including, but not
limited to x-rays, routine tests and treatment, and/or hospitalization. I also give permission for the camp to
arrange related transportation. I agree to the release of any records necessary for treatment, referral, billing,
or insurance purposes.
In the event I cannot be reached in an emergency, I hereby give permission to the medical professional
selected by the camp to secure and administer treatment, including hospitalization, for the person named
above. This completed form may be photocopied for trips out of camp.
Signature of Parent/Guardian or Adult Staff Member_____________________________________________
Print name___________________________________________ Date_______________________________
Health
History

To be completed by Parent/Guardian or Adult Staff Member.

Allergies List all known.
Medication allergies (list)

Describe allergic reaction and treatment/management of the reaction.

_______________________________
_______________________________
_______________________________

______________________________________________
______________________________________________
______________________________________________

Food allergies (list)

Describe allergic reaction and treatment/management of the reaction.

_______________________________
_______________________________
_______________________________

______________________________________________
______________________________________________
______________________________________________

Other allergies (list) include insect stings, hay fever, asthma, animal dander, etc. If the participant has an asthma
treatment plan, please attach a copy.
Describe allergic reaction and treatment/management of the reaction.

_______________________________
_______________________________
_______________________________
Medications being taken

______________________________________________
______________________________________________
______________________________________________

This person takes NO medications on a routine basis.

Medication Policy
All medication must be in its original container with the original label stating your name, name of medication,
doctors name and proper dosage. Medication dosage and frequency of dispensing must match the prescription
label. If there are any medication changes between the time you fill out the medical form and the first day of the
session, please notify the camp in writing. All prescription and non-prescription medication is kept in a secured
area at camp and dispensed by the camp medical professional.
_______________________

_______________

___________________

Medication

Dosage

Specific times taken each day

_______________________

_______________

___________________

Medication

Dosage

Specific times taken each day

_______________________

_______________

___________________

Medication

Dosage

Specific times taken each day

_______________________

_______________

___________________

Medication

Dosage

Specific times taken each day

________________
Reason for taking

________________
Reason for taking

________________
Reason for taking

________________
Reason for taking

Health History Questions (Explain any yes answers below.)

1. Had any recent injury, illness, or infectious disease?
2. Have a chronic or recurring illness/condition?
3. Ever been hospitalized?
4. Ever had surgery?
5. Have frequent headaches?
6. Ever had a head injury?
7. Ever been knocked unconscious?
8. Wear glasses, contacts, or protective eye wear?
9. Ever had frequent ear infections?
10. Ever passed out during or after exercise?
11. Ever been dizzy during or after exercise
12. Ever had seizures?
13. Ever had chest pain during or after exercise?
14. Ever had high blood pressure?

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No
No
No
No

15. Ever been diagnosed with a heart murmur?

16. Ever had back problems?
17. Ever had problems with joints (knees, ankles)?
18. Have an orthodontic appliance being brought to camp?
19. Have any skin problems (itching, rash, acne)?
20. Have asthma?
21. Have diabetes?
22. Had mononucleosis in the past 12 months?
23. Had problems with diarrhea/constipation?
24. Have problems with sleepwalking?
25. If female, have an abnormal menstrual history?
26. Have a history of bed-wetting?
27. Ever had an eating disorder?
28. Ever had other emotional difficulties for which
professional help was sought?

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No
No
No

Yes No

Please explain any yes answers, noting the number of the questions.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Use this space to provide any additional information about the participants behavior and physical, emotional, or mental health about
which the camp should be aware.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Which of the following has the
participant had?
Date
Measles
____________
Chicken Pox
____________
German measles ____________
Mumps
____________
Hepatitis A
____________
Hepatitis B
____________
Hepatitis C
____________
TB Mantoux test
Date of last test
Result: Positive

____________
Negative

Please give all dates of immunization for:

Vacccine: Date
DTP
TD (tetanus/diphtheria)
Tetanus
Polio
MMR
or Measles
or Mumps
or Rubella
Haemophilius influenza B
Hepatitis B
Varicella (chicken pox)

Mo/Yr
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________

Mo/Yr
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________

Mo/Yr
_________
_________
_________
_________

Mo/Yr
_________
_________
_________
_________

_________
_________

_________

Mo/Yr
_________
_________
_________
_________

The camp medical professional may administer the following over the counter medications to my child during the
course of the summer season without first contacting me/other Parent/Guardian. Please indicate by checking yes or no
which medications you will or will not permit the camp medical professional to administer.
Robitussin DM (or generic equivalent)
Chloraseptic Spray
Milk of Magnesia
Maalox or other antacids
Benadryl
Neosporin (or generic equivalent)
Imodium

Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No

Advil (or generic Ibuprofen)

Tylenol
Sudafed
Cortisone cream
Caladryl
Solarcaine spray

Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No

As a Parent/Guardian of this participant, I give permission to the camp medical professional to provide/dispense the
medications listed above to my child.
Signature of Parent/Guardian (if under 18) ____________________________________ Date__________

Physician Information
Name of participants physician____________________________ Phone______________________
Practice name___________________ Practice address______________________________________
Name of participants dentist/orthodontist____________________________ Phone______________
Practice name___________________ Practice address______________________________________

Health Care Recommendations to be completed by Licensed Medical Provider

Participant name___________________________________________________________________
Last

First

Middle

I examined the camp participant on _____________. (Camp TEKO requires a physical exam within
24 months of camp attendance.)
BP______________ Weight______________

Height______________

The participant is under the care of a physician for the following conditions______________________
__________________________________________________________________________________
Recommendations and Restrictions at Camp
Treatment to be continued at camp______________________________________________________
__________________________________________________________________________________
Please review Medications being taken listed on page 2.
The medications, dosages, and schedules are appropriate.
The medications, dosages, and schedules are incorrect. Comments_______________________
__________________________________________________________________________________
Any medically prescribed meal plan or dietary restrictions____________________________________
__________________________________________________________________________________
Known allergies_____________________________________________________________________
__________________________________________________________________________________
Description of any limitation or restriction on camp activities_________________________________
__________________________________________________________________________________
Additional information for the camp medical professional____________________________________
__________________________________________________________________________________
__________________________________________________________________________________
In my opinion, the camp participant

IS

IS NOT

able to participate in an active camp program.

Signature of Licensed Medical Provider__________________________

Date_________________

Print name_________________________________ Phone__________________________________

This form must be returned via regular mail by May 15, 2012 to the following address:
Camp TEKO Staff Forms Temple Israel 2324 Emerson Avenue South Minneapolis, MN 55405.
If you have any questions regarding this form, please contact Andrea Gordon at 612-374-0321 (Temple Israel
office). During the summer season, you can reach the Camp TEKO office at 952-471-8216.