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Child’s Last Name:

Child’s First Name:

It is imperative that we know your child’s medical history in case of an emergency, and so that we can provide your child with the best care and experience. For your child’s benefit, please answer the following questions thoroughly. Circle the appropriate answer to each question, and explain your answers when necessary: 1. a. Does your child have frequent ear infections?

Yes

No

b. Does your child have seasonal allergies?

Yes

No

c. Does your child have any hearing problems?

Yes

No

d. Does your child have frequent nosebleeds?

Yes

No

e. Does your child have asthma? Yes No If yes, what precipitates the attacks? ____________________________________________________________________________ f. Does your child wear glasses? If yes, for what reason?

Yes Nearsighted

No

Farsighted

g. Does your child have frequent stomachaches or vomiting? Yes

Other_______ No

h. Has your child ever been allergic to any medicines? Yes No If yes, to what medicine? _______________________________________ i. Does your child have a chronic seizure disorder?

Yes

No

j. Is your child allergic to any foods? (ex. Nuts, dairy)

Yes

No

If yes, what foods? ____________________________________________ _________________________________________________________________ k. Has your child ever been allergic to any insect or bee stings? Yes If yes, what happens? What is the prescribed treatment?

No

l. Does your child need any restrictions or limits placed on her/his physical activity? Yes No If yes, please explain: __________________________________________ m. Does your child have any other health conditions that may require special attention? Yes

No

If yes, please explain: __________________________________________

n. Does your child take any regular medication? Yes No If yes, what is it? _____________________________________________ What is it for? ________________________________________________ 2. Please use the following space to share any other information about your child that you think it is important for us to know in order to provide the best possible experience. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________


Summer Youth Health Questionnaire