Step 1.This Form Must Be Fully Completed and Signed by the Applicant S

Form C-MossRehab Camp Independence 2016-Medical Information

DIRECTIONS FOR COMPLETION:

Step 1.This form must be fully completed and signed by the applicant’s

physician. No substitutions of this form will be accepted. All applicants

must have a medical examination within twelve months prior to the

start date of MossRehab Camp Independence which is June 19, 2016.

In order to be considered for admission to MossRehab Camp Independence, this form must be fully completed and received by MossRehab no later than Monday, April 11, 2016 no exceptions will be granted.

Step 2.Mail To:

MossRehab at Elkins Park

Attention: Recreation Therapy Department/Camp Independence

60 Township Line Road

Elkins Park, PA 19027

Fax To:

215-663-6417

Attention: Recreation Therapy Department/Camp Independence

PLEASE PRINT

Applicant’s Information

Applicant’s Name ______Date of Examination_____/_____/______

Disability or diagonosis______

Date of Birth______Age ______Gender: Male or Female

Height ______Weight______Blood Pressure ______Pulse ______

Immunizations History

Are applicant’s vaccinations immunizations on schedule / up-to-date?Yes No

Tetanus: Date of last booster: ______

* All applicants must have had a tetanus booster within the last 10 years to attend camp.*

PPD: Date of last test: ______ Positive or  Negative

If positive PPD, date of last chest x-ray: ______ Positive or  Negative

Shunt History

Does applicant have a shunt? Yes No

If “yes,” date of last shunt revision: ______

Seizures

Does applicant have seizures?Yes NoUnder control with medication?Yes No

What type of seizure? ______Duration of seizure? ______

Date of last seizure? ______How many seizures in the last six months? ______

Known precipitating factors (triggers): ______

Describe behavior before seizure:______

Describe behavior during seizure:______

Describe behavior after seizure:______

Describe protocol normally followed: ______

______

Please note: Applicant must be on a stable medication regime and NOT be in the processof changing

medication or altering the dosage of current medication forat least one month prior to camp.

Allergies /Diet

No Latex Allergy Yes Latex Allergy

(MossRehab Camp Independence strives to be a latex free environment.)

No Medication Allergies Yes Medication Allergies

If “yes,” list all medication allergies. Please be specific:

______

No Food Allergies Yes Food Allergies

If “yes,” list all food allergies. Please be specific:

______

NoSwallowing Issues YesSwallowing Issues

If “yes,” please explain:

______

No Dietary Modification Needed Yes Dietary Modification Needed

If “yes,” list all dietary modification needed (puree food, thick liquids). Please be specific:

______

Medications

List all medications currently used by applicant. If additional space is needed, please photocopy this part of the health form. Inhalers and EpiPen information must be included, even if they are for occasional or emergency use only.

Medication: ______
Strength: ______
Frequency: ______
Reason for medication:
______
Approximate date started:
______
 Temporary  Permanent / Medication: ______
Strength: ______
Frequency: ______
Reason for medication:
______
Approximate date started:
______
 Temporary  Permanent / Medication: ______
Strength: ______
Frequency: ______
Reason for medication:
______
Approximate date started:
______
 Temporary  Permanent
Medication: ______
Strength: ______
Frequency: ______
Reason for medication:
______
Approximate date started:
______
 Temporary  Permanent / Medication: ______
Strength: ______
Frequency: ______
Reason for medication:
______
Approximate date started:
______
 Temporary  Permanent / Medication: ______
Strength: ______
Frequency: ______
Reason for medication:
______
Approximate date started:
______
 Temporary  Permanent
Medication: ______
Strength: ______
Frequency: ______
Reason for medication:
______
Approximate date started:
______
 Temporary  Permanent / Medication: ______
Strength: ______
Frequency: ______
Reason for medication:
______
Approximate date started:
______
 Temporary  Permanent / Medication: ______
Strength: ______
Frequency: ______
Reason for medication:
______
Approximate date started:
______
 Temporary  Permanent
Medication: ______
Strength: ______
Frequency: ______
Reason for medication:
______
Approximate date started:
______
 Temporary  Permanent / Medication: ______
Strength: ______
Frequency: ______
Reason for medication:
______
Approximate date started:
______
 Temporary  Permanent / Medication: ______
Strength: ______
Frequency: ______
Reason for medication:
______
Approximate date started:
______
 Temporary  Permanent

Speech

 Normal

 Mildly Affected  Moderately Affected  Severely Affected

 Few Words

 Non-Verbal

If applicant has partial or total loss of hearing,please explain the best way to communicatewithhim/her:

______

Communication

Can applicant communicate wants/needs? Yes  No

Is applicant able to communicate pain? Yes  No

Does applicant understand and respond to yes/no questions? Yes  No

Method(s) of communication:

 Verbal

 Sign Language

 CommunicationBoard

 Communication Device

 Points

 Grunts

 Gestures

 iPad

 Writing

 Other:______

Further communication instructions and assistance required:

______

Travel

Has the applicant traveled outside the country in the past 9 months? Yes  No

If “yes”explain below. Please name countries visited and dates of travel:

______

Health History

Eye/Vision Problems Yes  No

Requires glasses/contacts/protective eyewear

Ear/Hearing Problems Yes  No

Requires hearing aides

General / Precautions

M.R.S.A. / V.R.E. Yes  No

Hepatitis Yes  No

Recent Infectious Disease Yes  No

Recent Injury  Yes  No

Recurrent/Chronic Illness Yes  No

Blood Disorder Yes  No

Anemia Yes  No

Blood Clots Yes  No

Skin Problems Yes  No

Pressure Ulcers/Wounds Yes  No

Cancer  Yes  No

Lyme Disease Yes  No

Lupus  Yes  No

Edema Yes  No

If “yes” to any of the above, please explain:

______

Respiratory Health

Asthma/Breathing Problems Yes  No

Sinusitis/Bronchitis/Pneumonia Yes  No

C.O.P.D.  Yes  No

Sleep Apnea Yes  No

If “yes” to any of the above, please explain:

______

Cardiovascular Health

Artery/Vascular Disease Yes  No

Congenital Heart Disease Yes  No

Congestive Heart Failure  Yes  No

Heart Attack  Yes  No

Chest Pain Yes  No

Cardiac Arrhythmia Yes  No

High Blood Pressure  Yes  No

Elevated Cholesterol Yes  No

Implantable Devices  Yes  No

Chest pain / Fainting with physical activity Yes  No

If “yes” to any of the above, please explain:

______

Endocrine Health

Diabetes  Yes  No

Hypoglycemia / Hyperglycemia (circle)

Insulin Dependent Yes  No

Osteoporosis / Osteopenia  Yes  No

Thyroid Problems Yes  No

If “yes” to any of the above, please explain:

______

Neurological Health

Cerebral Palsy Yes  No

Charcot-Marie-Tooth Disease Yes  No

Muscular Dystrophy Yes  No

Traumatic/Brain Injury Yes  No

Chiari Malformation Yes  No

Hydrocephalus Yes  No

Migraines/Frequent Headaches Yes  No

Fainting/Dizziness Yes  No

Stroke/TIA Yes  No

Hemiplegia/ Hemiparesis Yes  No

Spina Bifida Yes  No

Spinal Cord Injury Yes  No

Paraplegia Yes  No

Quadriplegia Yes  No

Multiple Sclerosis Yes  No

Parkinson’s Disease Yes  No

ALS/ Lou Gehrig's Disease Yes  No

Fibromyalgia Yes  No

Neuropathy Yes  No

If “yes” to any of the above, please explain:

______

Musculoskeletal Health

Back / Neck / Joint Problems Yes  No

Arthritis Yes  No

Osteoarthritis / Rheumatoid Arthritis (circle)

Gout Yes  No

Degenerative Joint Disease Yes  No

Scoliosis Yes  No

Joint Replacement Yes  No

Amputation Yes  No

Fractures Yes  No

If “yes” to any of the above, please explain:

______

Gastrointestinal Health

Frequent Nausea/Vomiting Yes  No

Acid Reflux (G.E.R.D.)  Yes  No

Stomach Problems  Yes  No

Gall Bladder Problems Yes  No

Irritable Bowel Syndrome  Yes  No

Diarrhea  Yes  No

Constipation  Yes  No

Incontinence of Bowel Yes  No

If “yes” to any of the above, please explain:

______

Genitourinary Health

Kidney Problems Yes  No

Bladder Problems Yes  No

Frequent Urinary Tract Infections Yes  No

Incontinence of Urine Yes  No

Intermittent incontinence Yes  No

(i.e., night-time)

Female Applicant:

Menstrual Problems Yes  No

Vaginal Infections Yes  No

Date of last menstrual period:

If “yes” to any of the above, please explain:

______

Hospitalizations / Surgical History

Surgical ProceduresMonth/YearSurgical ProceduresMonth/Year

______

Most Recent Hospitalization(s):

Date(s)______

Reason(s):______

______

Psychological / Emotional / Social / Behavioral Health

Psychiatric Condition(s) Yes  No

Depression Yes  No

Anxiety Yes  No

Eating Disorder Yes  No

Sleep Disorders Yes  No

Problems falling asleep Yes  No

Sleepwalking Yes  No

Has the applicant:

Ever been treated for emotional or behavioral difficulties?  Yes  No
In the past 12 months, seen a professional to address

mental/emotional/behavioral health concerns?  Yes  No

Had a significant life event that continues to impact the applicant’s

daily life? (History of abuse, death of a loved one, family changes,

survived a tragedy, other) Yes  No

Please explain “yes” answers in the space below, referencing the question number in your response. The camp administrator may contact you for additional information.

______

Restrictions

Activity Restriction(s) (swimming, etc.). Please list:

______

Dietary Restriction(s) (sugar, caffeine etc.). Please list:

______

Non-Prescription Medications

The following non-prescription medications may be stocked in the camp health center and are used on an as needed basis to manage illness and injury. Medication will be given as directed on the label, unless otherwise instructed by physician. Cross out those the applicant should not be given.

Acetaminophen (Tylenol)

Ibuprofen (Advil, Motrin)

Phenylephrine Decongestant (Sudafed PE)

Pseudoephedrine Decongestant (Sudafed)

Cough syrup (Robitussin)

Sore Throat Spray

Generic Cough Drops

Antihistamine/Allergy Medicine (Benadryl)

Calamine Lotion

Antibiotic Cream

Aloe

Laxatives for Constipation (Ex-Lax)

Bismuth Subsalicylate for Diarrhea (Kaopectate, Pepto-Bismol)

I have examined the above name applicant and have reviewed their health history. In my opinion thisapplicant is capable of physically engaging in MossRehab Camp Independenceexcept for the restriction (s)noted above.

Physician’s Name (please print) ______

Physician’s Phone Number: ______

Physician’s Address: ______City: ______State: ______ZIP: ______

Physician Signature: ______Date: ______

Physician’s License Number: ______State: ______