Medical History Form Old - Center for Courageous Kids

Title

First Name:*

Last Name:*

Date of Birth*

Gender*

Male
Female

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone Number*

Cell Phone Number*

Email Address*

Session Attending*

Emergency Contact

Name*

Relationship to you*

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone Number*

Cell Phone Number*

Date of Last Tetanus Shot*

Height

Weight

Allergies (medication, food, and contact items like insect bites):*

Physical restrictions or limitations to activity:*

Prescription medications or over the counter medications: (Summer counselors will have meds stored in medical center.)

Please describe any prescriptions medications (if applicable):*

Digital Signature*

In case of accident or illness, medical services may be provided by camp medical/nursing staff. In the event of an emergency and you are unable to give consent for care, the medical center staff is authorized to carry out any procedures deemed necessary. Staff members and volunteers assume financial responsibility for all medical expenses incurred while at camp. Medical insurance information is requested in the event a referral of an injured or ill staff/volunteer becomes necessary. I have read, understand and agree by the above. I attest that I am physically fit for camp and there are no medical restrictions that would prevent me from performing the essential functions of my job. I understand that The Center for Courageous Kids assumes no responsibility for any pre-existing injury or illness.

Date*

The Center for Courageous Kids Tuberculosis (TB) Risk Factor Screening

Have you had an unexplained fever, poor appetite, persistent cough, night sweats, fatigue, spitting up blood, or unexplained weight loss in the past year?*

Yes
No

Are you an immigrant from OR have traveled to a country (within the last year) with a high incidence of TB? (Caribbean, Latin America, Africa, and Asia, excluding Japan.)*

Yes
No

Have you had household contact with an individual who immigrated from a country with a high incidence of TB? (Caribbean, Latin America, Africa, and Asia, excluding Japan) or an individual who has TB?*

Yes
No

Have you had exposure to individuals in the past year who are HIV-infected, homeless, institutionalized, users of illicit drugs, or incarcerated?*

Yes
No

Do you have HIV infection, chronic renal failure, malnutrition, reticuloendothelial diseases, other immunodeficiencies, or receiving immunosuppressive therapy?*

Yes
No

I have previously tested positive on a TB skin test. (If yes, please send copy of Chest xray.)*

Yes
No

If you answered YES to any of the questions above, please submit documentation of a TB skin test (Mantoux) with your medical form. If the TB skin test is positive, you will need to submit evidence of a chest x-ray report. If you answered NO to all the above questions, please sign below: