MossRehab



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 19027OR Fax To: 215-663-6417Attention: Recreation Therapy Department/Camp IndependencePLEASE PRINT Applicant’s InformationApplicant’s Name ___________________________Date of Examination_____/_____/______Disability or diagonosis___________________________________________________________Date of Birth________ Age ________ Gender: Male or Female Height ________ Weight_______ Blood Pressure _________ Pulse _________ Immunizations HistoryAre applicant’s vaccinations immunizations on schedule / up-to-date??Yes ?NoTetanus: 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 ? NegativeIf positive PPD, date of last chest x-ray: ______________? Positive or ? NegativeShunt HistoryDoes applicant have a shunt? ?Yes ?NoIf “yes,” date of last shunt revision: __________________________SeizuresDoes 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 process of changingmedication or altering the dosage of current medication for at 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 AllergiesIf “yes,” list all medication allergies. Please be specific: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________? No Food Allergies? Yes Food AllergiesIf “yes,” list all food allergies. Please be specific:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________? No Swallowing Issues? Yes Swallowing IssuesIf “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 ? PermanentMedication: _________________Strength: ___________Frequency: _______________Reason for medication:___________________________Approximate date started: ________________? Temporary ? PermanentMedication: _________________Strength: ___________Frequency: _______________Reason for medication:___________________________Approximate date started: ________________? Temporary ? PermanentMedication: _________________Strength: ___________Frequency: _______________Reason for medication:___________________________Approximate date started: ________________? Temporary ? PermanentMedication: _________________Strength: ___________Frequency: _______________Reason for medication:___________________________Approximate date started: ________________? Temporary ? PermanentMedication: _________________Strength: ___________Frequency: _______________Reason for medication:___________________________Approximate date started: ________________? Temporary ? PermanentMedication: _________________Strength: ___________Frequency: _______________Reason for medication:___________________________Approximate date started: ________________? Temporary ? PermanentMedication: _________________Strength: ___________Frequency: _______________Reason for medication:___________________________Approximate date started: ________________? Temporary ? PermanentMedication: _________________Strength: ___________Frequency: _______________Reason for medication:___________________________Approximate date started: ________________? Temporary ? PermanentMedication: _________________Strength: ___________Frequency: _______________Reason for medication:___________________________Approximate date started: ________________? Temporary ? PermanentMedication: _________________Strength: ___________Frequency: _______________Reason for medication:___________________________Approximate date started: ________________? Temporary ? PermanentMedication: _________________Strength: ___________Frequency: _______________Reason for medication:___________________________Approximate date started: ________________? Temporary ? PermanentSpeech? Normal? Mildly Affected ? Moderately Affected ? Severely Affected? Few Words? Non-VerbalIf applicant has partial or total loss of hearing, please explain the best way to communicate with him/her:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________CommunicationCan applicant communicate wants/needs?? Yes ? NoIs applicant able to communicate pain?? Yes ? NoDoes applicant understand and respond to yes/no questions?? Yes ? NoMethod(s) of communication:? Verbal? Sign Language ? Communication Board ? Communication Device ? Points ? Grunts ? Gestures ? iPad ? Writing? Other:_______________Further communication instructions and assistance required:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________TravelHas the applicant traveled outside the country in the past 9 months?? Yes ? NoIf “yes”explain below. Please name countries visited and dates of travel:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________Health HistoryEye/Vision Problems? Yes ? NoRequires glasses/contacts/protective eyewearEar/Hearing Problems? Yes ? NoRequires hearing aidesGeneral / PrecautionsM.R.S.A. / V.R.E.? Yes ? No Hepatitis? Yes ? NoRecent Infectious Disease? Yes ? No Recent Injury ? Yes ? NoRecurrent/Chronic Illness? Yes ? NoBlood Disorder? Yes ? NoAnemia? Yes ? NoBlood Clots? Yes ? NoSkin Problems? Yes ? NoPressure Ulcers/Wounds? Yes ? NoCancer ? Yes ? NoLyme Disease? Yes ? NoLupus ? Yes ? NoEdema? Yes ? NoIf “yes” to any of the above, please explain:_______________________________________________________________________________________________________________________________________________________________Respiratory HealthAsthma/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 HealthArtery/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 ? NoElevated 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 HealthDiabetes ? Yes ? No Hypoglycemia / Hyperglycemia (circle) Insulin Dependent? Yes ? NoOsteoporosis / Osteopenia ? Yes ? NoThyroid 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 ? NoTraumatic/Brain Injury? Yes ? No Chiari Malformation? Yes ? No Hydrocephalus? Yes ? NoMigraines/Frequent Headaches? Yes ? NoFainting/Dizziness? Yes ? No Stroke/TIA? Yes ? No Hemiplegia/ Hemiparesis? Yes ? NoSpina Bifida? Yes ? NoSpinal Cord Injury? Yes ? NoParaplegia? Yes ? NoQuadriplegia? Yes ? No Multiple Sclerosis? Yes ? NoParkinson’s Disease? Yes ? No ALS/ Lou Gehrig's Disease? Yes ? NoFibromyalgia? Yes ? No Neuropathy? Yes ? No If “yes” to any of the above, please explain:_______________________________________________________________________________________________________________________________________________________________Musculoskeletal HealthBack / Neck / Joint Problems? Yes ? NoArthritis? Yes ? No Osteoarthritis / Rheumatoid Arthritis (circle)Gout? Yes ? No Degenerative Joint Disease? Yes ? No Scoliosis? Yes ? NoJoint Replacement? Yes ? No Amputation? Yes ? NoFractures? Yes ? NoIf “yes” to any of the above, please explain:_______________________________________________________________________________________________________________________________________________________________Gastrointestinal HealthFrequent Nausea/Vomiting? Yes ? NoAcid Reflux (G.E.R.D.) ? Yes ? No Stomach Problems ? Yes ? No Gall Bladder Problems? Yes ? No Irritable Bowel Syndrome ? Yes ? No Diarrhea ? Yes ? NoConstipation ? Yes ? No Incontinence of Bowel? Yes ? NoIf “yes” to any of the above, please explain:_______________________________________________________________________________________________________________________________________________________________Genitourinary HealthKidney Problems? Yes ? No Bladder Problems? Yes ? NoFrequent Urinary Tract Infections? Yes ? No Incontinence of Urine? Yes ? NoIntermittent incontinence? Yes ? No(i.e., night-time) Female Applicant:Menstrual Problems? Yes ? NoVaginal Infections? Yes ? No Date of last menstrual period:If “yes” to any of the above, please explain:_______________________________________________________________________________________________________________________________________________________________Hospitalizations / Surgical HistorySurgical ProceduresMonth/YearSurgical ProceduresMonth/Year______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Most Recent Hospitalization(s):Date(s)________________ Reason(s):________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Psychological / Emotional / Social / Behavioral HealthPsychiatric Condition(s)? Yes ? NoDepression? Yes ? NoAnxiety? Yes ? No Eating Disorder? Yes ? NoSleep Disorders? Yes ? NoProblems falling asleep? Yes ? NoSleepwalking? Yes ? No Has the applicant:Ever been treated for emotional or behavioral difficulties? ? Yes ? NoIn the past 12 months, seen a professional to address mental/emotional/behavioral health concerns? ? Yes ? NoHad 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 ? NoPlease explain “yes” answers in the space below, referencing the question number in your response. The camp administrator may contact you for additional information. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________RestrictionsActivity Restriction(s) (swimming, etc.). Please list:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________Dietary Restriction(s) (sugar, caffeine etc.). Please list:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________Non-Prescription MedicationsThe 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 SprayGeneric Cough DropsAntihistamine/Allergy Medicine (Benadryl)Calamine Lotion Antibiotic CreamAloeLaxatives 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 this applicant is capable of physically engaging in MossRehab Camp Independence except 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: ________________ ................
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