Please explain any “yes” answers, noting the number of the questions.
Which of the following
has the participant had?
o Measles
o Chicken pox
o German measles
o Mumps
o Hepatitis A
o Hepatitis B
o Hepatitis C
TB Mantoux Test
Date of last test ________________
Result:
o Positive o Negative
Please give all dates of immunization for:
Vaccine:
Dates:
DTP
TD (tetanus/diphtheria)
Tetanus
Polio
MMR
or Measles
or Mumps
or Rubella
Haemophilus influenza B
Hepatitis B
Varicella (chicken pox)
Use this space to provide any additional information about the participant’s behavior
and physical, emotional, or mental health about which the camp should be aware.
Name of family physician _______________________________________________ Phone __________________________
Address ______________________________________________________________________________________________
Name of family dentist/orthodontist _______________________________________ Phone __________________________
Address ______________________________________________________________________________________________
Mo/Yr
Mo/Yr
Mo/Yr
Mo/Yr
Mo/Yr
Mo/Yr
General Questions (Explain “yes” answers below.)
Has/does the participant:
Yes No
Yes No
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? ..........................
15. Ever been diagnosed with a heart murmur? .....
16. Ever had back problems? ...................................
17. Ever had problems with joints
(e.g., knees, ankles)? .........................................
18. Have an orthodontic appliance being
brought to camp? ...............................................
19. Have any skin problems (e.g., itching,
rash, acne)? ........................................................
20. Have diabetes? ...................................................
21. Have asthma? .....................................................
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 emotional difficulties for which
professional help was sought? ...........................
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
o o
