| Document Date: 2013-07-29 17:24:06
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Facility DO NOT WRITE IN THIS BOX REVIEW FOR CAMP / / IndustryTerm insurance / / MedicalCondition Allergies / ADHD / TB / Hypertension / Positive Explain Allergies / disease / Seizures / Fainting / Muscular/skeletal injuries / No Date Tetanus_________________________ Pertussis________________________ Diphtheria / Measles / autism / Hepatitis A______________________ Hepatitis B______________________ Influenza / orthopedic injury / Tetanus / Heart disease / Diabetes / Allergies/anaphylaxis / Mumps__________________________ Rubella__________________________ Polio / HEALTH HISTORY Allergies / sleep apnea / Ankles (both) Nose Spine Normal Abnormal Yes No Explain Any Abnormalities Throat Lungs Other Neurological Heart Contacts Abdomen Dentures Genitalia Braces Skin Emotional adjustment Tuberculosis / high blood pressure / uncontrolled heart disease / emotional difficulties Behavioral disorders / Asperger syndrome / Seizures Last seizure / MedicalTreatment immunization / immunizations / orthopedic surgery / Surgery / / / Position orthopedic surgeon / GENERAL INFORMATION Name / Adult leader / nurse / physician / treating physician / event leader / physician assistant / medical advisors / / Product EpiPen / Abdominal/digestive problems Surgery Serious injury Other Medication / / Technology cellular telephone / CAD / / URL www.learningforlife.org / /
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Learning for Life Annual Health and Medical Record (Valid for 12 calendar months) Policy on Use of the Learning for Life Annual Health and Medical Record In order to provide better care for its members and to assist them