Hemophilia/Bleeding Disorders Health Form
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 INCOMPLETEPolio 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