Pinecrest Adventures Camp

Camper MEDICAL INFORMATIONFORM 2013

Camper Name: ______

Please complete the following medical information form for your child, which will be kept confidential. Return the completed and signed form with the other application forms. If you require assistance filling out this form contact Lori at the Bleeding Disorder Program519-685-8500 extension 53582.

GENETIC BLEEDING DISORDER: (Please check all that apply)

___ Factor V Deficiency (Factor Five) Severity: ___Mild ___Moderate ___Severe

___ Factor VII Deficiency (Factor Seven) Inhibitor: ___No ___Yes

___ Factor VIII Deficiency (Hemophilia A, Factor Eight)

___ Factor IX Deficiency (Hemophilia B, Factor Nine)

___ Factor XI Deficiency (Factor Eleven)

___ Von Willebrand Disease Type: ______

___ Platelet Disorder Type: ______

___ Hemophilia Carrier Factor VIII____ Factor IX_____

___ Other

TREATMENT INFORMATION:

  1. Name of product used: ______
  2. Is your child on home infusion program?Yes ___ No ___

If yes, who regularly administers factor at home?______

  1. Does your child have a port?Yes ___ No ___
  2. Please describe your child's participation in his/her infusions: ______

______

  1. What is your child's treatment type?Prophylaxis ___ On-Demand ___ (Check one)
  2. Please describe prophylaxis schedule including dosage/days of treatment ______
  3. Describe treatment of episodic bleeding events

______

  1. Bleeding Episodes in last 6 months

Number of joint bleeds_____ Location ______

Number of muscle bleeds _____Location ______

Number of other bleeds _____Location ______

  1. Does your child have a target joint/area of frequent bleeding?Yes ___ No ___

If yesplease describe any special treatment ______

  1. Date of last visit to Bleeding Disorders Program: ______

Your child with hemophilia will be encouraged to learn reconstitution, venipuncture and self-infusionwhile at camp.

____ Check here if you do not want your child instructed in venipuncture and self-infusion.

  1. Does your child have any physical limitation that might have an impact on his/her activities at camp? Yes ___ No ___ If yes please describe in detail: ______

______

  1. Does your child use any special protective, assistive or corrective equipment/appliances (i.e. cane, crutches, wheelchair)? Yes ___ No ___ If yes please describe in detail:

______

If yes, will your child bring equipment/appliances to camp? Yes ___ No ___

HEALTH HISTORY:

The following information must be filled in by parent/guardian. Any changes to thisinformation must be provided to camp health personnel upon arrival at camp.

CURRENT/PAST MEDICAL CONDITIONS:

  1. Please check “Yes” if your child currently has or has history of the followingmedical conditions. Otherwise, please check “No”. Explain “Yes” answers below.

Yes ___ No ___AsthmaYes ___ No ___Shortness of breath/difficulty breathing

Yes ___ No ___Hay fever/seasonal allergyYes ___ No ___Heart disease/murmur

Yes ___ No ___High blood pressure Yes ___ No ___Chest pain

Yes ___ No ___Low blood pressureYes ___ No ___Frequent headaches

Yes ___ No ___Seizures/EpilepsyYes ___ No ___Head injury/concussion

Yes ___ No ___Diabetes Yes ___ No ___Dental problems/toothache

Yes ___ No ___Sores in mouthYes ___ No ___Abnormal menstrual history

Yes ___ No ___Diarrhea/constipation Yes ___ No ___Stomach problems/ulcers/colitis

Yes ___ No ___Kidney/bladder problem Yes ___ No ___Liver disease/Hepatitis

Yes ___ No ___Vision problemsYes ___ No ___Frequent ear infections

Yes ___ No ___Skin problems/rashesYes ___ No ___Bone/joint problem

Yes ___ No ___Back ProblemYes ___ No ___Hearing problem/hearing aid

Yes ___ No ___ADD/ADHD Yes ___ No ___Bed-wetting

Please explain anything to which you answered yes: ______

  1. Does your child have any emotional or mental health concerns?Yes ___ No ___

If yes please explain: ______

______

  1. Does your child wear an orthodontic appliance?Yes ___ No ___

If yes please explain: ______

  1. Does your child wear glasses or contacts?Yes ___ No ___
  2. Has your child ever had surgery?Yes ___ No ___

List surgeries/year: ______

  1. Has your child been hospitalized in the last year?Yes ___ No ___

If yes please describe: ______

______

  1. Has your child had recent illness, injury, infectious disease? Yes ___ No ___

If yes please describe: ______

______

  1. Has your child had recent fever/sore throat?Yes ___ No ___

If yes please explain: ______

  1. Have there been any changes in your child's health status in the last year?Yes ___ No ___

If yesplease explain: ______

______

MEDICATIONS:

Please list ALL medicines and vitamin supplements that are required during camp. Be sure to send all medications in the original bottle, labelled with your child’s name, the name of the medicine in the bottle, and the directions for giving it. All prescription medications must have the original label containing your child’s prescription. All medications will be dispensed by the nursing staff.

Drug/Vitamin Name / Dose / Frequency / Special Instructions (w/meals, etc)

ALLERGIES:

Does your child have any allergies to medications, food, insectsor other items? Yes ___ No ___

If yes, please explain: ______

______

DIETARY CONCERNS:

Outline any dietary concerns your child may have (lactose intolerance, vegetarian, vegan, celiac, etc.) ______

______

IMMUNIZATION DATES:

Are your child’s vaccinations up to date?Yes ___ No ___

If no what is he/she missing? ______

Date of last tetanus shot ______

Has your child had the chicken pox or the vaccination?DiseaseYes ___ No ___

VaccinationYes ___ No ___

Is there anything else you would like us to know about your child?

______

______

Signature of Parent or Guardian Date