HEALTH EXAMINATION FORM

Name____________________________________________________________Birthdate_______________________Age________________
Parent or Guardian________________________________________________Phone____________________________________________
In case of emergency notify__________________________________________________________________________________________
Address________________________________________________________________________________________________________________
HEALTH HISTORY:(Check by giving appropriate date)
Frequent colds_____________________________Kidney Trouble________________________Chicken pox___________________
Abscessed Ears_____________________________Convulsions____________________________Mump_________________________
Fainting________________________________________Sleep Walking___________________Whooping cough_________________
Frequent Sore Throat________________________________________Heart trouble_________________________________________
Sinusitis______________________________Measles____________________Bronchitis_____________
Athlete’s Foot____________________________Stomach upsets____________________
Constipation_____________________________Tuberculosis_______________________________
Operation or other serious injuries_______________________________________________
Allergic Reactions:
Penicillin:________________________________Other drugs:____________________________
_____________________________________________________________________________________

Any specific activities to be encourage?_____________________________________________________

RESTRICTED______________________________________________________________________
General condition:_______________________________________________________________
Physician:__________________________________________________________________________

IMPORTANT: Please notify the Training /Camp Staff is this applicant is exposed
to any communicable disease during the three weeks prior to camp attendance.