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Mishkan Israel Day Camp
Youth Camp Health Examination Record
To be completed by parent or guardian
Name ___________________ Sex______________ Age______ Birth Date _____________
Address ____________________ Phone ( ) ______________________________
Health History (Check)
Chickenpox _____ Measles _____ German Measles ______ Mumps______ Whooping Cough _____ Other please specify _______________________
Additional Details ______________________________________________________
Allergies (Check)
Hay Fever __ Insect sting (specify) ___ Asthma ___ Poison Ivy, Oak, etc. ___ Drug(s)
Specify ________________________________________________________________
Foods (specify)__________________________________________________________
Chronic/Recurring Illness (Check)
Earaches _____Throat problems _____ Sinus ______ Infections _____ Heart _____ Stomach _____ Epilepsy _____ Rheumatic Fever _____ Diabetes _____ Menstrual Problems_____ Medications being taken (Name & Specify for what illness) _____________________________ Operations, injuries special restrictions if any ______________________ Details______________
Immunizations
Date Booster
Diphtheria________ ___________
Tetanus__________ ___________
Pertussis_________ ___________
Polio____________ ___________
Measles__________ ___________
Mumps__________ ___________
Rubella__________ ___________
Other____________ ___________
Parent or Guardian Authorization (Required for all persons under age 18)
This health history is correct so far as I know and the
person named above has permission to participate in all camp activities
except as noted by me or the examining physician. If I cannot be reached in
an emergency, God forbid, I hereby give my full permission to the physician
selected by the camp director to hospitalize, secure proper treatment for,
and order injection, anesthesia for surgery for the person named above, or
perform any other medical procedure to remedy the situation.
Signature ________________________
Date_________________________
Physical Examination to be completed by a licensed physician
Good (1) – Satisfactory (2) Not Satisfactory (3) Not examined)
Height _____ Weight ____ B.P.____ Skin ____
Nose ____ Eyes ____ Glasses/Contacts____ Required ____ Condition ____
Ears ____ Hearing Right ____ Hearing Left ____ Throat ____ Teeth ____ Heart
____ Lungs ____ Skeletal ____ Abdomen ____ Genitalia ____
Hernia ____ Extremities ____ Tests Urinalysis Glucose _____ Albumin____
Tuberculin Testing (Type) ____ If Indicated Blood Count ____
Restrictions/Limitations (Including Diet) ____________ Medications
_________________
Recommendations _______________________
The above name person is in satisfactory condition and
may engage in all camp activities except as noted date ____________
Examining Physician ________________ State Licensed No._____________ License
No.______________
Phone ( )________________
Address ___________________________________________
Hospital (If applicable)
_______________________________________
Emergency Phone _________________