HEMOPHILIA/BLEEDING DISORDERS HEALTH FORM

PLEASE PRINT

Application Deadline: June 15, 2017

Name______Birth date ______Sex ______Age ______

Last First Initial

Parent or Guardian______

**please indicate preferred number below

Home Phone ______Cell Phone______Work Phone______

Address ______

Street and NumberCity StateZip

Emergency Name ______Phone ______

(If you cannot be reached)

Physician’s Name______Phone______

TYPE OF BLEEDING DISORDER(VIII, IX, VWD, etc)______

(Circle one)Severe Moderate Mild

Inhibitor:  Yes (Bethesda Units) ______ No

INFUSION PRODUCT (be specific) ______

Dose: Major bleed ______u Minor bleed ______u

Prophylaxis Yes NoHome infusion? Yes NoDoes child do self-infusion? Yes No

Prophy DOSE & SCHEDULE______

Hospitalizations in the past year  Yes No If yes, describe______

Major sites of hemorrhage during the past year (target joints)______

List surgical procedures, dates and/or major complications in the past year: ______

Does your child have any drug allergies? Yes No If yes, specify drug and reaction______

______

Bee sting, food or other allergies Yes No If yes, please explain food or other and reaction______

Does your child have any physical restrictions that would prevent him/her from participating in any camp activities?

Yes No If yes, pleaseexplain______

Does your child use splints, braces, crutches or wheelchair occasionally during a bleed? Yes No If yes, please list

______

Does your child have other medical problems such as heart disease, kidney disease, seizures, diabetes, history of tuberculosis, etc? Please be specific______

Has your child ever been separated from parents and siblings in the past? Yes No Does he/she have problems with this? Yes No

HEMOPHILIA/BLEEDING DISORDERS HEALTH FORM

IMMUNIZATION RECORD REQUIRED BY MINNESOTA STATE LAW. CAMPERS CANNOT BE ACCEPTED IF THIS IS INCOMPLETE
Polio Vaccine Date ______Tdap booster Date ______
MMR Vaccine Date ______Hepatitis A Vaccine Date ______
PCV Date ______Hepatitis B Vaccine Date ______
MCV Vaccine** Date ______**(MCV (Meningococcal) for ages 12 and above only)
IMPORTANT – This CONSENT FORM section must be signed by custodial parent/guardian
I will supply all needed factor concentrate and DDAVP for use at camp. If my child is on prophylaxis, I will supply those scheduled doses, plus two extra. If my child treats only when bleeding occurs, I will send at least two doses with him/her. I understand that my child will not be accepted at camp or on the bus without the needed medications.
**If your child has an inhibitor please discuss factor and plan for camp with your HTC nurse or provider.
Parent/guardian signature ______
I hereby authorize the use of donated factor product (recombinant factor VIII, recombinant factor IX, or vW containing factor as appropriate) as needed for emergencies if there is no product from home remaining.
Parent/guardian signature ______
I have read and understand all the above information. I agree not to send my child to camp if he/she has been exposed to a contagious disease within three weeks of the date he/she is to report to camp and to notify my child’s hemophilia center and the camp director immediately. I hereby give permission to the hemophilia camp medical personnel to order x-rays, routine tests, and treatment for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the camp physician to hospitalize and secure proper treatment for my child as named above. This form may be photocopied for use out of camp.
______
Signature of custodial parent/guardian if applicant is under 18 Date

PLEASE NOTE: When camper arrives at camp, the nurse will collect all medications. Be sure medications are labeled with camper’s name, name of drug, dosage, medication time, doctor, prescription number and pharmacy. Unused medicine will be returned to camper the last day of camp.

Page 1 of 2To be completed by Parent/Guardian

HEMOPHILIA/BLEEDING DISORDERS

HEALTH FORM

MEDICAL EXAMINATION

(To be filled out by licensed Physician) PLEASE PRINT

Application Deadline JUNE 15th, 2017

Child’s Name ______Date of examination ______

Height ______Weight ______Blood Pressure ______

Positive physical findings ______

______

Are pupils equal and responsive to light at baseline? Yes No If no, please describe ______

______

Major sites of hemorrhage during the past year (target joints) ______

______

Bleeding Disorder: type & severity______Factor level ______

Inhibitor status and date drawn______

Infusion product ______Dosage: Minor bleed ______Major bleed ______

Prophylaxis DOSE & SCHEDULE______

Please list all medications that the individual is now taking and which are necessary while at camp (include PRN pain medications and non-prescription meds)

Medication Dosage Frequency

______

______

______

______

Does the individual use Amicar or Lysteda as needed? Yes No If yes, please describe use ______

______

Are there any special concerns, such as ear tubes, shunts, catheters, etc? Please specify and describe ______

______

Port? Yes No Hickman? Yes No If yes, how often is dressing changed? ______

Is the individual restricted from: Swimming Overnights Other? If so, specify______

______

Does the individual have a history of seizures? Yes No How often do they occur? ______

Date of last tetanus toxoid ______(Should be administered with this physical if not up to date.)

I understand that while attending Minnesota Hemophilia Camp, my patient will receive needed medical services as determined, authorized and prescribed by medical personnel staffing the camp.

Return this form to:Sarah CurtsPh# 952-852-0101 ext 300

True

10509 108th St. NW

Annandale, MN 55302

______

Doctor’s Name/Address/Phone (Please Print)

______

Doctor’s SignatureDate

Page 1 of 1To be completed by Physician