Health record 2-27-08

To Parents/Guardians:
Camp Kaizen
founded by Nick & Cindi Bollettieri
located in the beautiful Northeast Kingdom of Vermont - (Summer Contact) (Winter Contact)
Lyndonville, VT 05851 Bradenton, FL 34282 “worth the effort”
VT Fax: (802) 626-9263 FL Fax: (941) 727-0344 Camper Health Form
The information on this form is not part of the Camper’s acceptance process, but is gathered to assist us in identifying appropriate care.
Health history must be filled out by Parents/Guardians of minor. (An update is required annually)
Camper’s Name: __________________________________ Date of Birth: ______________ Age (as of first day of camp): ___________

Last First Middle Month/Day/Year Year and Months Camper’s Home Address: ___________________________________________ City: ___________________State: _________ Zip: ___________ Camper’s Email: ___________________________ Camper’s Home Phone: (______) ________________ School Grade next September: __________
Parent/Guardian with legal custody to be contacted in case of illness or injury.
Name of Parent/Guardian: _________________________________ Relationship: _________________ Phone: (______) ____________________ Address: ___________________________________________________________________________________________________________ Preferred Phone: (______) ___________________ Home Phone: (______) ___________________ Work Phone: (______) ___________________ Cell Phone: (______) _______________________ E-mail: _____________________________________________________________________
Second Parent/Guardian or other emergency contact.
Name of Parent/Guardian: _________________________________ Relationship: __________________ Phone: (______) ___________________ Additional contact in event parent(s)/(or guardian) cannot be reached.
Name(s): ______________________________________________ Relationship: __________________ Phone: (______) __________________ Medical Insurance Information:
This camper is covered by family medical/hospital insurance:
Insurance Company: ______________________________ Policy Number: _____________________ Subscriber: ___________________________ Insurance Company Phone Number: (____) ____________ Address: ___________________________ City: _____________ State: ____ Zip: _____ Please include four copies of your insurance card: copy both sides of the card so information is readable.
Name of Primary Physician: _____________________________________________ Phone number:_____________________________
Name of Dentist: _______________________________________________________ Phone number:_____________________________
Name of Orthodontist: _________________________________________________ Phone number:_____________________________
Any Known Allergies: Yes No (if yes, please list all) Describe Reaction and Management of Reaction
Food Allergies: ___________________________________________ ___________________________________________
Medication Allergies: ______________________________________ ___________________________________________
Environmental Allergies (insect stings, hay fever, etc.) : _____________ ___________________________________________ Other: _________________________________________________ ___________________________________________ Parent/Guardian Authorization for Health Care:
This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp
activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine test and treatment related
to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospital-
ize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a “need to know”
basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat
my child and these providers may talk with the program and camp staff about my child’s health status.
Signature of Custodial Relationship
Parent/Guardian __________________________________________ Date _________________ to Camper____________________________ If for religious or other reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance. Medications Currently Being Taken Camper Name:_____________________
“Medication” is any substance a person takes to maintain and/or improve their health. This includes vitamins and natural
remedies. Please list ALL medications (including over-the-counter or non-prescription drugs) taken routinely. Bring enough
medication to last the entire time at Camp. Keep it in the original packaging/bottle that identifies the prescribing physician (if
a prescription drug), the name of the medication, the dosage, and the frequency of administration. □ This Camper takes NO medications on a routine basis.
□ This Camper takes medications as follows: (Please indicate entire medication list by attaching additional pages.
Please also include any medications Camper takes during the school year that the Camper may not be taking during Camp Medication #1: _______________________ Dosage: _____________ Specific times taken each day: ________________
Reason for taking: _________________________________________________________________________________
Medication #2: _______________________ Dosage: _____________ Specific times taken each day: ________________
Reason for taking: _________________________________________________________________________________
Medication #3: _______________________ Dosage: _____________ Specific times taken each day: ________________
Reason for taking: _________________________________________________________________________________ The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Cross out those the camper should not be given.
Dextromethorphan cough syrup (Robitussin DM) Diphenhydramine antihistamine/allergy medicine (Benadryl) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto Bismol) Other OTC medications camper should not be given:___________ _____________________________________________________ Note: At this time, Camp Kaizen does not have the ability to accommodate dietary restrictions.
Explain any restrictions to activity (e.g. what can not be done, what adaptation or limitations are necessary) __________________________________________________________________________________________________________ __________________________________________________________________________________________________________
Which of the following has the Camper had?

Yes No Date:
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Please explain “Yes” answers:
_______________________________________________________________________________________________ _______________________________________________________________________________________________ Camp Kaizen Camper Health Record 022608 Gen eral Questions (Explain “yes” answers below) Camper Name:___________________________

Has/does the Camper: Yes No Yes No
1. Ever have nightmares or night terrors?. 22. Ever had problems with “cutting” or injuring
2. Have a chronic or recurring illness/condition? self on purpose?.
3. Ever been hospitalized?. 23. Have an orthodontic appliance being
4. Ever had surgery?. brought to camp?.
5. Have frequent headaches?. 24. Have any skin problems (e.g., itching, rash,
6. Ever had a head injury/concussion?. eczema, acne, poison ivy)?.
7. Ever been knocked unconscious?. 25. Have diabetes?.
8. Wear glasses, contacts/protective eye wear? 26. Have asthma?. .
9. Ever had frequent ear infections?. 27. Had mononucleosis in the past 12 months?.
10. Ever passed out during or after exercise?. 28. Had problems with diarrhea/constipation?.
11. Ever been dizzy during or after exercise?. 29. Have problems with sleepwalking?.
12. Ever had an eating disorder?. 30. Has started menses?.
13. Ever had chest pain during or after exercise? 31. Has a history of abnormal menstrual
14. Ever had high blood pressure?. periods? .
15. Ever been diagnosed with a heart murmur?. 32. Has been informed about menses?.
16. Ever had back problems: pain or injury?. 33. Ever had emotional difficulties for which
17. Has any family member or relative died of professional help was sought?.
heart problems or sudden death before age 50?. 34. Has your child ever experienced racing of the
18. Is there any family history of heart problems heart or skipped heartbeats?.
(examples are enlarged heart, cardiomyopathy, 35. Has a physician ever denied or restricted your
prolong QT interval, abnormal EKG, abnormal participation in sports for any heart problems?
heart rhythm)? 36. Have a history of bed-wetting? .
19. Had any recent injury, illness or 37. Does your child have any phobias? .
infectious disease?. 38. Does your child have seizures or epilepsy?.
20. Ever had problems with joints 39. Ever been treated by a psychiatrist or
(e.g., knees, ankles)?. psychologist?.
21. Does Camper consistently wear support brace 40. Traveled outside the country in the past
for specific joints (e.g., knee, ankle, wrist)?. nine (9) months?.
Please explain “Yes” answers in the space below, noting the number of the question(s).
For travel outside the country, please name countries visited. Mental, Emotional and Social Health: Check “Yes” or “No” for each statement.
Has the Camper: Yes No
1. Ever been treated for Attention Deficit Disorder (ADD) or Attention Deficit/Hyperactivity Disorder (AD/HD)?.
2. Ever been treated for emotional or behavioral difficulties or an eating disorder? ………………………………………………………………………………………….
3. During the past 12 months, seen a professional to address mental/emotional health concerns?.
4. Had a significant life event that continues to affect the camper’s life? ……………………………………………………………………………………………………….…….
(History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others) Please explain “Yes” answers in the space below, noting the number of the question(s).
The camp may contact you for additional information. Camp Kaizen Camper Health Record 022608 Please give Dates of Immunization for all of the following: Camper Name:________________________
Immunization History: Provide the month and year for each immunization. Starred (*) immunizations must be current. Copies of immunization forms
from health-care providers or state or local government are acceptable; please attach to this form.
Diptheria, Tetanus, Pertussis* (DTaP) or (TdaP) TB Mantoux Test: Date of last test___________________________ Result: □ Positive □ Negative List any surgeries or hospitalizations:
What have We Forgotten to Ask? Please provide in the space below any additional information about the camper’s health that you think important
or that may affect the camper’s ability to fully participate in the camp program. Attach additional information if needed.
This health history is correct and complete as far as I know. The Camper herein named has permission to engage in all Camp Kaizen activities except as noted. I hereby give permission to Camp Kaizen to provide, seek, and consent to routine health care, administration of prescribed medications, and emergency treatment for my child, as may be necessary, including, but not limited to x-rays, routine tests and treatment, and/or hospitalization. I also give permission for Camp Kaizen to arrange related transportation. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. It is my intention that Camp Kaizen be treated as acting in loco parentis if the person herein named is a minor. Further, it is my intention that the appropriate repre- sentatives of Camp Kaizen be treated as “personal representatives” for the purposes of disclosing protected health information pursuant to the privacy regulations prom-ulgated pursuant to the Health Insurance Portability and Accountability Act of 1996. I hereby agree (pursuant to 45 CFR 164.510b) to the disclosure to Camp Kaizen Representatives of the protected health information of the person herein described, as necessary: (i) to provide relevant information to Camp Kaizen Representatives related to the person’s ability to participate in Camp Kaizen activities; and (ii) in the case of minors, to provide relevant information to Camp Kaizen Representatives to keep me informed of my child’s health status. In the event I can not be reached in an Emergency, I hereby give permission to the physician selected by Camp Kaizen to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips off the campus of Camp Kaizen.
Signature of Parent or Guardian: _______________________________________________________________________________________
Printed Name: ______________________________________________________________ Date of Completion: ___________________________________ ************************************************************************************************************************************************************************************************************************************************************************************************************************************************************ I also understand and agree to abide by any restrictions placed on my participation in Camp Kaizen activities. Signature of Minor Camper: __________________________________________________________________________________________
Printed Name: ______________________________________________________________ Date of Completion: ___________________________________ Camp Kaizen Camper Health Record 022608



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