Medical Form
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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 _________________

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