Universalhealthhistoryform.pdf

FOR OFFICE USE ONLY
Other Notes: _____________________________ ASTHMA CAMP UNIVERSA L HEALTH FORM

A. GENERAL INFORMATION - to be completed by parents
NAME OF CHILD _____________________________________________
Birthdate ________ Sex ___Female ___Male Age At Ca mp ____ Present grade (or recent past grade) ____ Father ___________________ Phone:Home (___)____________ Work (___)____________ Cell (___) ___________ Mother ___________________ Phone: Home (___)___________ Work (___)____________ Cell (___) ___________ or Guardians ___________________ Phone Home (___)______________ Work (___)_______________ Cell (___)___________ MAILING ADDRESS _____________________ City_____________State___ Zip Code ___________ Are parents living together? ___ Yes ___ No Are there any custody or visitation restrictions? If so, describe: ______________________________________________________________ IF NOT AVAILABLE IN AN EMERGENCY, PLEASE NOTIFY: (this must be filled out)
Name ____________________________ Relationship to child _____________ Phone(___)__________________ Name ____________________________ Relationship to child _____________ Phone(___)_______ ____________ ___Pediatrician ___Family Practitioner ___Don't Know ___Other Name of child's regular physician _____________________________ Phone ______________ Address _____________________________________ Does your child currently see an asthma specialist?___Yes ___No If so, which type? ____Allergist ____Pulmonologist ____Don't Know Name of child's asthma physician _____________________________ Phone ______________ Address _____________________________________________________________ What does your child have for medical insurance? ___PPO ___HMO ___Medic-Aid ___Medi-Cal ___None ___Don't Know Name of Health Insurance Plan _________________________________ Policy or Group Number _________________________________ Has your child attended this Camp before? ____Yes ____No
If so, for how many sessions? ____sessions
Has your child attended other asthma camps? ____Yes ____No
If so, for how many sessions? ____sessions Has your child ever been to an overnight camp? ____Yes ____No T-shirt size: _____ S _____M _____L _____XL B. MEDICATIONS - to be completed by parent and preferably verified by physician
1. My child takes the following ASTHMA medications EVERY DAY:
(puffs, tabs,
Specific
Medication
Generic Name
How often
instructions
ampules,
Advair 100/50 Discushaler Fluticasone/Salmeterol Advair 250/50 Discushaler Fluticasone/Salmeterol Advair 500/50 Discushaler Fluticasone/Salmeterol (EVERY DAY Medications continued)
(puffs, tabs,
Specific
Medication
Generic Name
How Often?
instructions
ampules,
Theophylline time -release Theophylline tab Theophylline time - release Theophylline tab Theophylline time -release Theophylline tab
Additional Specific Instructions:
_______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 2. The following ASTHMA medications are given ONLY IF NEEDED:
(puffs, tabs,
Specific
Medication
Generic Name
How Often?
instructions
ampules,
(IF NEEDED Medications continued)
(puffs, tabs,
Specific
Medication
Generic Name
How Often?
instructions
ampules,
Prednisone liquid 5 mg/5 ml Prednisone liquid
Additional Specific Instructions:
_______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 3. Other medications that your child takes:
Medication
Strength tabs, caps,
How often?
Specific Instructions
ampules,
Additional Specific Instructions:
_______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Is your child on allergy injections? ____Yes ____No
**NOTE: No allergy shots will be given at camp (unless there are special circumstances).
Does your child use a spacer or assisting device with his/her inhaler? ____Yes ____No If so, which one? _________________________ Is there any medication treatment you prefer not be used at camp for you child? __________________________________________________________________ Does your child have a specific Asthma Action Plan? ____Yes ____No If so, please attach to this form.
C. HISTORY OF ASTHMA - to be completed by parent and preferably verified by physician
1) How long has your child had asthma? ____years
2) Within the past 5 years:
A) Has your child been admitted to the hospital for asthma? ____Yes ____No How many times total? ____
B) Has your child been in an intensive care unit for asthma? ____Yes ____No How many times total? ____
3) Within the past three months (on the average):
A) How many nights per week, on the average, does your child wake up because of asthma or coughing? ____nights
per week
B) How much does your child's asthma interfere with exercise?
____None ____Some ____Moderate ____A lot
4) Within this past year only, how many times did your child need to (list number of times)
A) Stay home from school because of asthma? ____days
B) Be taken to the doctor's office because of difficulty with his or her asthma (not including routine office visits)?
____times
C) Be take to the emergency room or urgent care clinic because of asthma difficulty? ____times
D) Be admitted to the hospital for asthma? ____Yes ____No
How many times total? ____ How old was he or she each time? ____ E) Be in an intensive care unit for asthma? ____Yes ____No How many times total? ____
5) How many times (in the past year only) have oral corticosterioids been used for the control of your child's asthma?
(Note: Oral corticosteroids are medications taken by mouth in either pill or liquid form, and are usually used when other medications
cannot adequately control asthma symptoms. Names of oral corticosteroids include: PILLS: Prednisone, Medrol, Deltasone, Decadron
and others LIQUIDS: Pediapred, Prelone, Liquidpred, OraPred, BubblyPred and others.)
____courses of oral corticosteroids have been taken in the past year. Date of most recent course? ____
6) Who is responsible for giving your child's asthma medication at home?

7) Does your child use a peak flow meter? ____Yes ____No If yes, what brand? __________________________
If yes, what is your child's normal reading? ______ Does your child use it routinely? ____Yes ____No If so, how often? ____time(s) a day ____time(s) a week
8) On a scale of 0 -10, how bad (severe) has your child's asthma been over the last year? (CIRCLE ONE NUMBER ONLY!)

(NO ASTHMA) 0 1 2 3 4 5 6 7 8 9 10 (SEVERE ASTHMA) Describe any emotional effects you have observed in your child due to asthma : ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ D. HISTORY OF ALLERGIES - to be completed by parent and preferable verified by physician

Is our child allergic to any MEDICATION? (Penicillin, sulfa, etc.)? ____Yes ____No
If yes, please list:
Reactions*
Age of Last
Medication Name
(be specific with the symptoms, how severe, when they start, etc.)
Reaction
Is our child allergic to any FOODS? ____Yes ____No If yes, please list: Reactions*
Age of Last
Food Name
(be specific with the symptoms, how severe, when they start, etc.)
Reaction
Is our child allergic to any ANIMALS? ____Yes ____No If yes, please list: Reactions*
Age of Last
(be specific with the symptoms, how severe, when they start, etc.)
Reaction
Is our child allergic to any INSECTS? ____Yes ____No If yes, please list: Reactions*
Age of Last
(be specific with the symptoms, how severe, when they start, etc.)
Reaction
*Reactions include: Severe total body reaction (anaphylaxis); shock; skin problems (hives, redness, blistering, itchy skin, swelling); breathing problems ( wheeze, cough, chest tightness); mouth problems (swollen lips, rash, tongue swelling, itchy); throat problems (swollen, itchy, scratchy); eye problems (swollen, itchy, watery); nose problems (itchy, runny, stuffy, sneezing); intestinal problems (abdominal pain, vomiting, diarrhea); behavior/sleep problems (stimulation, hyper, strange behavior, sleepiness, trouble sleeping) Was emergency treatment needed for any of the reactions listed above (e.g. 911, ER visit, Urgent Care, EpiPen?)? ____Yes ____No If so, explain: _________________________________________________________________________ _________________________________________________________________________
E. OTHER INFORMATION - to be completed by parent
Has your child had the following illnesses?
Date of most recent tetanus booster: __________ DPT, Polio and MMR immunizations up-to-date? ____Yes ____No Specifically, does your child have any of the following problems? Are there any other medical problems or conditions your child has that the camp should know about? ____Yes ____No If yes to any of the above questions, explain here: ______________________________________________________________________ ______________________________________________________________________ Has your child ever camped out with the family? ____Yes ____No If yes, were there any problems? ____Yes ____No If yes, explain : ______________________________________________________________________ ______________________________________________________________________ Has your child been to the mountains recently? ____Yes ____No Any previous problems with altitude? ____Yes ____No If yes, explain: _____________________________________________________________________ _____________________________________________________________________ Has your child ever been away from home and parents for more than a few days? ____Yes ____No If so, were there any problems? ________________________________________________ Do you anticipate any problems with homesickness at asthma camp? _______________________________________________________ Does your child feel embarassed at school or in public if he/she has to take an inhaler or nebulizer treatment? ____Yes ____No Do you anticipate any activity restrictions? ____Yes ____No If so, explain: ______________________________________________________________ Are there any present physical education restrictions at school? ____Yes ____No If so, explain: _____________________________________________________________ Is there anything else you feel camp staff should know about your child? ____Yes ____No If so, explain: ________________________________________________________________________ ________________________________________________________________________ HOW DID YOU HEAR ABOUT ASTHMA CAMP?
Please check one:
___ Healthcare Provider’s Office
A little of the
None of the
All of the time Most of the time Some of the time
PARENT’S AUTHORIZATION

Date Rec’d
Both sides must be completed for application to be considered PARTICIPATION AND EMERGENCY TREATMENT WAIVER In consideration for being allowed to register and participate in Camp parent/guardian I hereby release the Association, its Incorporators, Physicians, Board Members, Officers,
Employees, Agents, Independent Contractors and Volunteer Workers from any liability for injuries which are
sustained during the camp, including any necessary transportation. The child herein described has permission to
engage in all scheduled activities except as noted by the physician or parent/guardian. I hereby give permission to
the camp physician to initiate and provide any necessary treatments, including transporting to the nearest certified
emergency facility. If hospitalization is required, the child is to be referred to an appropriate physician and all
treatments will be at my expense.
PHOTOGRAPHY, VIDEO AND PROMOTIONAL RELEASE I do hereby acknowledge and authorize Camp (insert sponsoring organization(s) here) to take and use photographs, video and written comments of or by my child for promotional and informational materials. Further, I agree to release and discharge (insert sponsoring organization(s) here) and its sponsors from any and all liability in connection with the use of such photographs, videos and written comments of or by my child. RELEASE FOR TRANSPORT HOME At the conclusion of camp, the Camp Staff may release my child to myself or to the individual(s) designa ted below. Under no circumstances will your child be released to anyone not specified by you. Picture ID may be required. AUTHORIZATION TO RELEASE MEDICAL DATA
I do hereby authorize Camp (insert Camp Name here) and (insert sponsoring organization(s) here) release medical data for the purpose of compiling and assessing national asthma medical information. I understand that all data will be analyzed in aggregate form protecting the confidentiality of my child. CAMPER CODE OF CONDUCT
(Please review with your child)
It is our hope that everyone that participates in our program will have a positive experience that will last a lifetime.
To help everyone get the most out of their camp experience, we have set up a list of ground rules to help parents
and children understand what we expect at camp. We recognize the special needs of our campers and will as much
as possible; individualize the rules according to the needs and abilities of each camper.
Camp has four basic rules that we explain to the children and also post in the cabins. We have these rules so that
everyone can be assured of a positive experience.
• Respect yourself, others and property. This means abusiveness toward others or using inappropriate
language, fighting, stealing, etc. It also covers property damage, graffiti or vandalism. Respect yourself, refers to keeping your things picked up, personal hygiene and taking your medication on time.
• Participate in camp activities. It is camp’s responsibility to know where all the campers are at all times. We
ask campers to be at all activities unless excused by staff. Campers cannot be left alone in their cabin.
• Follow directions. There are a lot of fun things to do at camp but every activity has rules so we can operate the
activity safely and appropriately. We ask the campers to follow staff direction during these activities. • No put-downs. Examples of this would include teasing, name-calling, racial slurs or inappropriate practical

If we do have a problem with inappropriate behavior, we have a camper behavior response policy. The counselor
will start by giving the child a warning, then a time-out with an explanation and discussion on what is causing the
problem. If the counselor needs help, a behavioral specialist or the designated healthcare team supervisor on site
will work with the child to help avoid further problems. We will also call home to find out if the parents have any
suggestions on ways to deter the inappropriate behavior. As a last resort, we may need to send a child home.
Sometimes in the case of severe homesickness or if misbehavior could cause immediate harm to themselves or
others, we reserve the right to immediately ask that the child be removed from camp.
It is our hope that each child will go home with great memories of camp. These rules are designed to protect the
camper’s experience so that one unruly child won’t ruin the experience for the rest. If you have any questions or
comments, please fell free to call. It is our mission to provide a quality experience for everyone.
I understand and accept that my child must abide by the Camper Code of Conduct


I agree to abide by the Camper Code of Conduct
ASTHMA CAMP MEDICAL HISTORY AND PHYSICAL EXAMINATION - to be completed by physician
An important note to Healthcare Providers:
This Medical History and Physical Examination form is a mandatory part of your patient’s asthma camp application. If applicable, please try to simplify the medication regime that the child follows during camp. For example: if a medication can be given TID, with meals, instead of QID (or BID instead of TID), this would be h elpful for the child and the medical personnel. Furthermore, inhalation therapy with a nebulizer can be time consuming for the child at camp; please carefully review the child’s need for this form of therapy. Also, allergy shots will not be given at camp.

Child’s name
Immunization Dates:
Please circle Yes (Y) or No (N)
Y / N Date of last appointment
2. Have there been any hospitalizations for asthma in the PAST 5 YEARS? Y / N How many?
Date of most recent hospitalization (month, year) a. In the ICU or intubated because of asthma in the PAST 5 YEARS? Y / N How many times?
Date of most recent ICU admittance or intubation? / / b. On oral corticosteroids within the PAST YEAR? Y / N How many times?
c. Hospitalized for reasons other than asthma? Y / N How many times?
4. Has this child received the following tests or evaluations in the past year? 5. Does this child have any of the following problems? 6. Does the Camp Healthcare team need to be aware of any of the following: a. Known medical problems, besides asthma? b. Known behavioral or psychological issues? c. Foods that must be completely eliminated from this patient’s camp diet? d. Other allergy or sensitivity problems? f. Treatments you prefer not be used at camp?
g. Restrictions/limitations on participation in any asthma camp activities? Please explain any “yes” answers (please be specific) 7. Based on the NHLBI’s guidelines severity classification, how would you classify this child’s asthma? 8. How would you rate the severity of this child’s asthma on a scale of 0 – 10? (Circle one number only) MEDICATIONS
Please include asthma and non-asthma medications
DRUG NAME (include if it is an inhaler, nebulizer or pill) STRENGTH
FREQUENCY
__________________________________________________ _____________ __________________________________________________ _____________ __________________________________________________ _____________ __________________________________________________ _____________ __________________________________________________ _____________ __________________________________________________ _____________ __________________________________________________ _____________ __________________________________________________ _____________ __________________________________________________ _____________ __________________________________________________ _____________ ALLERGY INFORMATION
Is this child allergic to any:
MEDICATION? ____Yes ____ No
Medication
Reaction (be specific)
Age of Last Reaction
________________________________________ ________________________________________ ________________________________________ ________________________________________ FOODS? ____ Yes ____ No
Reaction (be specific)
Age of Last Reaction
________________________________________ ________________________________________ ________________________________________ ________________________________________ ANIMALS or INSECTS? ____ Yes ____ No
Animal or Insect
Reaction (be specific)
Age of Last Reaction
________________________________________ ________________________________________ ________________________________________ ________________________________________ HEALTHCARE PROVDER’S AUTHORIZATION
I have examined the above camp applicant. My signature below indicates that I believe this patient is able to participate in an active camp program designed for children with asthma. ___________________________________________________ ________________________________________________ ___________________________________________________ ___________________________________________________ __________________________________________________ _____________________ Would you volunteer at camp? ____Y ____N Please return to:
By
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Source: http://www.ghschildrens.org/mydocuments/healthform1.pdf