CAMPER HEALTH HISTORY RECORD
Camper's Personal Information
Camper's Healthcare Provider Information
Allergies
Medication
Dose
Medication or Treatment
When do you give it at home?
Reason for taking medication
Asthma
Asthma Triggers
(check all that apply)
Sign/Symptoms
of asthma episode
Frequency of episodes
How episode is managed
Immunizations
upload immunization record OR complete section below
List the MONTH, DAY, AND YEAR your child received each of the following immunizations. DO NOT USE checkmark or X except to answer the question about chickenpox, Tdap or Td. If you do not have an immunization record for this child at home, contact your doctor or public health department to obtain it. A copy of the child's complete immunization record (Wisconsin residents check www.dhfswir.org) may be uploaded in lieu of completing this section by using the +Upload button above.
DTaP/DTP/DT/Td
(Diphtheria, Tetanus, Pertussis)
Adolescent booster (mark which)
Polio
Hepatitis B
MMR (measles, mumps, rubella)
Meningococcal Conjugate Vaccine (MCV)*
Hepatitis A
Varicella (chickenpox) Vaccine -
vaccine is needed only if your child has not had chickenpox disease. See below:
Has your child had Varicella (chickenpox) disease? Please check appropriate box and provide the date (if known):
Influenza (date of most recent dose):
Vaccines above marked with * are routinely recommended at age 11-12 years.
List vaccine(s) not received:
Other Medical Conditions
Signature (use mouse to draw signature)
The information included on this form is complete and accurate to the best of my knowledge.
medical history form submitted!
