Pharmacie française en ligne: Acheter des antibiotiques sans ordonnance en ligne prix bas et Livraison rapide.

Girlscoutsnca.org

CAMP HEALTH HISTORY
This form to be completed by the parent/guardian. REQUIRED for ALL (Children and Adults; Day, Resident, Troop Core, and Family)
Name ____________________________________________________________________________________ Date of Birth _________________________________ Age ___________ Gender ____________ Height _____________ Weight _____________ Parent/Guardian _______________________________________________________________________________________________________ Address _____________________________________________ City _____________________________ State _______ Zip _______________ Parent’s Phone #s (home)(_____) ____________________(work)(_____) _____________________ (cell)(_____)_________________________ In Emergency Notify _______________________________________________________ Relationship __________________________________ Please list someone other than Parent/Guardian listed above Address _____________________________________________ City _____________________________ State _______ Zip _______________ Emergency Phone #s (home)(_____) _____________________ (work)(_____) _____________________ (cell)(_____)_____________________ Primary Care Physician _________________________________________________________ Phone (_____)_____________________________ Health Insurance Carrier ________________________________ contract number________________ Named Insured_____________________________ named Insured ______________________

RESTRICTIONS:
List any special medical or dietary regimen to be followed _________________________________________________
Is the camper allowed to participate in all camp activities? □ Yes □ No
If not, please list restricted activities ___________________________________________________________________

MEDICATIONS:
Is this person routinely taking medication including prescription, over-the-counter, vitamins, or alternative medication? □ Yes
If so, please list all _________________________________________________________________________________________
List any medication regularly taken by this person that he/she will not take while in attendance ______________________________

Check all medications that may be given by Health Supervisor, if needed (usually generic):

□ Cortizone/Anti-Itch Cream □ Benadryl topical □ Other __________________________________________________________
ALLERGIES: Is this person allergic to:

DISEASES:
□ Pol en* □ Plants* ____________________ □ Insects*____________________________ *Explain severity & treatment ______________________________________________________ □ Other ___________

HEALTH HISTORY:
(Check if there is any history of.)
□ Asthma
□ Kidney Problems □ Musculoskeletal Disorders Please explain any checked items ___________________________________________________________________
Please list any problems related to menstruation ________________________________________________________
Has the participant been exposed to any communicable diseases within the past 30 days? □ Yes □ No
If so, please explain ________________________________________________________________________________

PAST MEDICAL TREATMENT/CONDITIONS: (list & give dates):
Operations/serious injuries __________________________________________________________________________
Hospitalizations ___________________________________________________________________________________
Other illness/disease _______________________________________________________________________________
CORRECTIVE APPLIANCE OR DEVICE:
Does this person use or wear a corrective appliance/device for mobility, vision, hearing, dental or have a prosthesis?
□ Yes
If so, please explain ____________________________________________________
BEHAVIORAL, EMOTIONAL, & MENTAL HEALTH:
Are there any behavioral, emotional, or mental health conditions that may require medication, treatment, restrictions,
or special consideration? □ Yes □ No
If so, please list___________________________________________ List any additional information about the attendee's behavioral, physical, emotional, or mental health that staff should be aware of:______________________________________________________________________________________ Is the camper able to change clothes, toilet, shower, and manage personal hygiene with minimal/no assistance? Is the camper able to follow directions and function as part of a group? □ Yes □ No

IMMUNIZATIONS/VACCINATIONS:
Is the campers exempt from immunizations due to religious/ medical reasons?
(If yes, a note will be required stating reason(s) for the exemption)
If not exempt, is the camper current on all recommended immunizations and vaccinations? □ Yes □ No Date of last Tetanus ______

This HEALTH HISTORY is accurate and complete to the best of my knowledge. The participant may engage in all activities
except as noted above. I give full permission for EMERGENCY MEDICAL TREATMENT and/or anesthesia to be
administered by qualified personnel as deemed necessary by the camp Health Supervisor or the Camp Director.
Parent / Guardian signature ______________________________________________________ Date _______________________

Source: http://girlscoutsnca.org/wp-content/uploads/2009HEALTHHISTORY_000.pdf

Microsoft word - ley n 635-95.doc

Ley Nº 635/95 Que reglamenta la Justicia Electoral EL CONGRESO DE LA NACIÓN PARAGUAYA SANCIONA CON FUERZA DE LEY: NATURALEZA Y COMPOSICIÓN Artículo 1º .- Naturaleza y composición. La Justicia Electoral goza de autarquía administrativa y autonomía jurisdiccional dentro de los límites establecidos en la presente ley. Está compuesta de los siguientes organismos: a) El

Microsoft word - psychosomatik in der medizin.doc

Psychosomatik in der Medizin – im Spannungsfeld zwischen Patient und Doppelblindversuch - einige Gedanken dazu Von Dr. med. Ulrike Banis In der ärztlichen Ausbildung gab es während meines Studiums ein einziges Seminar zur „Psychosomatik“, in dem die Biographie des Patienten und seine seelischen Verletzungen und Traumen zur Erklärung seiner Symptome herangezogen wurden. Dieses Semi

Copyright © 2010-2014 Pharmacy Drugs Pdf