Here is a Neftaly Medical History Form Template that captures essential health information to ensure participants’ safety during the camp:
Neftaly Basketball Camp Medical History Form
Participant Information
- Full Name: _____________________________________________
- Date of Birth: ___________________________________________
- Gender:
☐ Male
☐ Female
☐ Other: _______________ - Address:
Street: _________________________________________________
City: _________________________________________________
State: _________________________________________________
Zip Code: _____________________________________________ - Emergency Contact Name: ______________________________
- Emergency Contact Phone Number: ______________________
- Emergency Contact Relationship: _________________________
Health Information
- Primary Care Physician: __________________________________
- Physician Phone Number: _________________________________
- Insurance Provider: ______________________________________
- Insurance Policy Number: _________________________________
- Does the participant have any allergies?
☐ Yes ☐ No
If yes, please list all allergies (e.g., food, medication, environmental): - Does the participant have any medical conditions?
☐ Yes ☐ No
If yes, please describe the condition(s): - Does the participant take any prescription medications?
☐ Yes ☐ No
If yes, please list the medications: - Does the participant have a history of any of the following? (Check all that apply)
☐ Asthma
☐ Diabetes
☐ Seizures
☐ Heart condition
☐ High blood pressure
☐ Concussion history
☐ Other (please specify): ___________________________ - Has the participant had any recent surgeries or injuries?
☐ Yes ☐ No
If yes, please provide details:
Physical Activity
- Is the participant currently involved in regular physical activity?
☐ Yes ☐ No
If yes, please describe the type and frequency of activity: - Does the participant have any physical limitations or restrictions?
☐ Yes ☐ No
If yes, please specify: - Has the participant experienced any of the following in the past year? (Check all that apply)
☐ Chest pain or tightness
☐ Shortness of breath
☐ Fainting or dizziness
☐ Joint pain or swelling
☐ Other (please specify): ___________________________
Medications
- List all medications the participant will need during the camp:
- Does the participant need assistance with medication management?
☐ Yes ☐ No
If yes, please explain:
Immunization History
- Has the participant received all required vaccinations?
☐ Yes ☐ No
If no, please specify any missing vaccinations: - Date of Last Tetanus Shot: _______________________________
Consent for Medical Treatment
In the event of an emergency, I hereby give permission for Neftaly staff to obtain medical treatment for my child/participant as needed. I understand that all reasonable precautions will be taken to ensure the safety and well-being of the participant.
- Parent/Guardian Name: _________________________________
- Parent/Guardian Signature: _______________________________
- Date: _______________________
Medical Emergency Instructions
If there is a medical emergency, please provide any additional instructions or specific treatments that should be followed:
Additional Notes or Concerns
Please provide any other relevant health or medical information that we should be aware of to ensure the participant’s safety and comfort during the camp:
Acknowledgment of Accuracy
I confirm that all the information provided in this Medical History Form is accurate and complete to the best of my knowledge. I understand that I am responsible for informing Neftaly staff of any changes to the participant’s health information before or during the camp.
- Parent/Guardian Name: _________________________________
- Parent/Guardian Signature: _______________________________
- Date: _______________________
This template can be modified to include any additional information needed or to comply with specific camp regulations. The goal is to ensure that the camp staff is well-informed of any medical conditions, allergies, or restrictions to prioritize participant safety.