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CT Heart Camp Camper Medical Form

Child's First Name*

Child's Last Name*

First and Last Name of Parent or Guardian Completing the Form*

Medical Information

Primary Care Physician*

Primary Care Physician Phone

Name of Child’s Cardiologist*

YNHH or CCMC?*

(If other please provide office location/phone number)

Child’s Cardiac Diagnosis*

Other Medical Problems (i.e. ADD, asthma, celiac, etc)*

Other Specialist 1 Name

Other Specialist 1 Specialty

Other Specialist 1 Phone

Other Specialist 2 Name

Other Specialist 2 Specialty

Other Specialist 2 Phone

Behavioral / Mental Health Specialist

Behavioral / Mental Health Specialist Phone

In the past 12 months has your child required surgery, procedures or hospitalization? *

Yes

No

If yes, please give date(s) and reason(s):

Allergens

Allergen (medications, foods, animals, insects, etc) 1

Reactions (be specific with the symptoms, how severe, when they start, etc.) 1

Age of Last Reaction 1

Allergen (medications, foods, animals, insects, etc) 2

Reactions (be specific with the symptoms, how severe, when they start, etc.) 2

Age of Last Reaction 2

Allergen (medications, foods, animals, insects, etc) 3

Reactions (be specific with the symptoms, how severe, when they start, etc.) 3

Age of Last Reaction 3

What is your usual response to an allergic reaction (medications, ice packs, etc)?

Does your child have any special diet restrictions or preferences (vegetarian, celiac, picky eater)?*

Does your child have any special needs or physical limitations?*

Does your child have any behavioral, developmental or emotional concerns? *

Yes

No

Does your child need special care or tutoring at school?*

Yes

No

Does your child need one-on-one supervision for activities/school? *

Yes

No

Does your child have an IEP or 504 plan at school?*

Yes

No

Has your child been to an overnight camp before?*

Yes

No

Is there something that scares your child?*

Yes

No

Is there anything else that you think we should know about your child?

Medications*

Medication, Strength, Time Taken, Directions, Prescriber

Insurance

Does your child have health insurance?*

Yes

No

Name of Health Insurance Plan

Policy Holder

Policy and/or Group Number

Upload a copy of your insurance card for emergency purposes

Let's Connect

106 Doral Farms Rd.

North Branford, CT 06471

203-499-8242

info@joeabatefoundation.org

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