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Microsoft word - sp_10_health_form

KEIO ACADEMY OF NEW YORK
SUMMER PROGRAM 2010
HEALTH REPORT FORM

Health history must be filled out by parents/guardian.
Health exam must be completed by a licensed medical personnel.
Name: ________________________________________________________ Birth Date: ______________________

Home Address: _____________________________________________________________________________________________________________
Social Security Number of Participant (if any): _______________________________________ Gender: ____Male ____Female
Parent/guardian: ___________________________________________

Phone (home) __________________ (cell) _________________________

Home Address: ______________________________________________________________________________________________________________
(If different from above)

Street Address
City State

Business Address: ______________________________________________________________

Phone: _____________________________________
Street Address
City State

Second parent, guardian, or emergency contact: ___________________________________________________________________________________
Address: _______________________________________________________ _______________ Phone: _____________________________________

Street Address
City State

Business Address: _______________________________________________ _______________ Phone: _____________________________________

Street Address
City State

Mandated by State
Parent/Guardian Authorizations: This health history is correct and complete to the best of my knowledge. The person herein described has
permission to engage in all program activities except as noted.
Consent for Treatment and Transportation:
I hereby give my permission to the authorize personnel of Keio Academy Summer Program to provide routine health care, administer prescribed
medication/s and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for
insurance purposes.
I give permission to the program to arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby
give permission to the physician selected by Keio Academy of NY to secure and administer treatment, including hospitalization, for the person
named above. This completed form may be photocopied for trips out of program. I also understand and agree to abide by any restrictions placed on
my child’s participation in program activities.
Signature of parent/guardian _________________________________________
Printed Name_______________________________________________________ Date______________________
Meningitis Waiver Mandated by State
New York State Public Health Law requires the operator of an overnight children’s program to maintain a completed response form for every
participant who attends program for seven (7) or more days. Check one and sign below. For more information about meningococcal disease, please
go to Center for Disease Control and Prevention website (www.cdc.gov/vaccines/pubs/vis/downloads/vis-mening.pdf).
_____ My child has had the meningococcal meningitis immunization (Menomune/Menactra) within the past 10 years. Date received: __________.
[Note: The vaccine’s protection last for approximately 3 to 5 years. Revaccination may be considered within 3-5 years.]

_____ I have read, or have had explained to me, the information regarding meningococcal meningitis disease. I understand the risks of not
receiving the vaccine. I have decided that my child will not obtain immunization against meningococcal meningitis disease.
Signed: ______________________________________________________________________ Date: _______________
(Parent/Guardian)

PARENT
Please double check to see that all information is filled in correctly and checked, and all signatures are in place.
PARENT’S SECTION (Must be completed by parent/guardian)

Health History
ALLERGIES:
List all known allergies and describe reaction and management of reaction on spaces provided below.
 No known allergies
________________________ _____________________________________________________________________
________________________ _____________________________________________________________________

RESTRICTIONS:
The following restrictions apply to this individual:
Dietary:
 Does not eat red meat
 Others (specify below) _______________________________________________________________________________________________
Activities:
Please explain if any (e.g. what cannot be done, what adaptations or limitations are necessary)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
GENERAL QUESTIONS: (Please check YES or NO and explain “yes” answers on spaces below)
Has/Does the participant:
1. Had any recent injury, illness or infectious disease? 2. Have a chronic or recurring illness/condition? 15. Ever been diagnosed with a heart murmur? 16. Have an orthodontic appliance brought to program? 17. Have any skin problems (e.g. itching, rash, acne)? 20. Had mononucleosis in the past 12 months? 8. Wear glasses, contacts, or protective eye wear? 21. Had problems with diarrhea/constipation? 10. Ever passed out during or after exercise? 23. If female, have an abnormal menstrual history? 11. Ever been dizzy during or after exercise? 24. Ever had problems with joints (e.g. knees, ankles?) 13. Ever had chest pain during or after exercise? 26. Ever had emotional difficulties for which
Please explain any “yes” answers, noting the number of the question.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Use this space to provide any additional information about the participant’s behavior and physical, emotional, or mental health about
which the program should be aware.
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Name of family physician _______________________________________ Phone
____________________
Address________________________________________________________________________________

Name of family dentist/orthodontist _____________________________ Phone
_____________________
Address________________________________________________________________________________
PHYSICIAN’S SECTION (Must be completed and signed by examining physician)

Student’s Name: _____________________________________________
________________________ ____________________

BP ______ Pulse ______Resp._____ Temp _____ Weight ________ Height _________
The studentis is not able to participate in strenuous physical activities.

The student is under the care of a physician for the following conditions:
_________________________________________________________________________________________
Known Allergies: _____ NKA ______Others (specify below)
__
________________________________________________________________________________________________
Description of any limitations or restrictions on program activities:
________________________________________________________________________________________________

Medications to be Administered at program:
Please check next to the following medications to authorize their utilization per package instructions for age and or weight:
 Acetaminophen  Ibuprofen
 Phenylephrine  Loratadine  1% Hydrocortisone Cream  Bacitracin ointment  Maalox /Rolaids  Imodium
Additional Medications and or Treatments to be administered while at program:
Medication/Treatment Name
Frequency/Schedule
Check box if the participant has had:
 Measles
 Chicken Pox  German Measles Mumps  Hepatitis A B C Please give dates of immunization:
Date of last PPD test ________________________ Chest X-ray (if positive PPD) Date:_________ Result:_______
Signature of Licensed Medical Personnel/Physician:
______________________________________________
Print Name: _________________________________________________ Title: ___________________________
Address: ____________________________________________________ Phone: ___________________________
Date of Physical Examination (Must be done within 12 months prior to program attendance): ___________________
Self Care/Self Administration
Students who need to carry any medication dispensed by school nurse:
I request that the above named child be permitted to administer his/her medications under the supervision of a staff member of the
program. She/he has been instructed in and understands the medication’s purpose, frequency, and appropriate method of use.
______________________________________ ______________________________________ ____________________
Physician’s Printed Name
Signature

As I consider him/her responsible, I will not hold Keio Academy of New York personnel responsible for any problems that may arise
with regards to my child’s self-administered medication.

PARENT Signature
________________________________________________________________ ___________________
Parent’s Printed Name
Signature

Source: http://www.keio.edu/summerprogram/SP_10_Health_Form.pdf

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