South Carolina FFA Center

Health History and Examination Form

Yellow highlighting indicates a field that is required to be filled out.

This form is required for all FFA members attending camp; it is not required for advisers or chaperones. This form should be filled out if even if another physical is provided. A Register Nurse may sign this form.

Name: ______Sex: ______Age: ______Birth date: ______

Parent or Guardian (or Spouse): ______

Home Address: ______Phone:______

Business Address: ______Phone: ______

Second Parent or Guardian or Emergency Contact: ______

Home Address: ______Phone:______

Business Address: ______Phone: ______

If not available in an emergency, notify:

Name: ______

Home Address: ______Phone:______

Medical Form.doc – Revised 8/22/16

Reviewed 6/20/16

Health History

(Check and give approximate dates.)

______Frequent Ear Infections

______Heart Defect/Disease

______Convulsions

______Diabetes

______Bleeding/Clotting Disorders

______Hypertension

______Mononucleosis

Diseases

______Chicken Pox

______Measles

______German Measles

______Mumps

Allergies

(Dates not needed.)

______Hay Fever

______Ivy Poisoning, etc.

______Insect Stings

______Penicillin

______Other Drugs

______Asthma

______Other (Specify)

______

______

Medical Form.doc – Revised 8/22/16

Reviewed 6/20/16

Operations or Serious Injuries (dates): ______

______

Chronic or recurring illness or medical condition: ______

______

Dietary Restrictions: ______

______

Other Diseases: ______

Name of dentist/orthodontist: ______Phone: ______

Name of family physician: ______Phone: ______

Do you carry family medical/hospital insurance? Yes / No (Please circle one.)

If so, indicate: Carrier ______Policy or Group #: ______

Carrier Address: ______

Suggestions on health related information for camp personnel: ______

______

______

Name of Camper: ______School: ______

Health History and Examination FormPage 2

For Female

Has this person menstruated? ______If not, has she been told about it? ______

If so, is her menstrual history normal? ______Special Consideration: ______

Important – This Box Must Be Completed for Attendance*

Immunization History

Required immunizations must be determined locally. Please record the date (month and year) of basic immunizations and most recent booster doses.

Vaccines / Year of Basic Immunization / Year of Last Booster
Diphtheria
Pertussis (Whooping Cough)
Tetanus
or / }DPT* / 1
2
3 / 1
2
Tetanus
Diphtheria
or / }TD*
Tetanus
Oral Polio (Sabin)* TOPV
Injectable Polio (Salk)
Measles (hard measles, red measles, rubeola)
Mumps
Rubella (German measles, 3-day measles)
Other
Tuberculin test given _____ (most recent)
Haemophilus influenza b (HIB)
Hepatitis B

Health Care Recommendations by Licensed Physician, Physician’s Assistant, or Registered Nurse

I have examined the above camp applicant. Date Examined:______

In my opinion, the above’s condition does / does not preclude his/her participation in an active camp program. (Please circle one.)

Height ______Weight______Blood Pressure ______

The applicant is under the care of a physician for the following condition(s): ______

______

______

Name of Camper: ______School:______

Health History and Examination FormPage 3

Current treatment (include current medications): ______

______

Explanation of any reported loss of consciousness, convulsion, or concussion ______

______

Does applicant have epilepsy? Yes / No (Please circle one.)

Does applicant have diabetes? Yes / No (Please circle one.)

Recommendations and Restrictions While at Camp

Any treatment to be continued at camp ______

______

Any medication to be administered at camp (specific dosages) ______

______

Any medically-prescribed meal plan or dietary restrictions ______

______

Any allergies (food, drugs, plants, insects, etc.) ______

______

Activities to be encouraged or limited ______

______

Additional health information ______

______

Medical Form.doc – Revised 8/22/16

Reviewed 6/20/16