Microsoft word - health form 08
Berkshire Humane Society ~ 214 Barker Road, Pittsfield, MA 01201 ~Camp Humane - 2009 Health Form
THIS SIDE TO BE FILLED OUT and SIGNED BY PARENT/GUARDIAN
BACK SIDE TO BE FILLED OUT
and SIGNED BY A PHYSICAN
This form MUST be received by the first day of camp or the child CANNOT attend camp.
Child’s Name_________________________ Date of Birth ___________ Age_____
Parent/Guardian____________________________________________________
Address____________________________________Email__________________
City____________________ State______ Zip_________
Home Phone_______________________ Work/Cell _______________________
Child’s health history (check illness child has had, with approximate dates):
Frequent ear infections _______ Chicken Pox _______
Allergies:
Heart defect/disease _________ Measles ___________
Pet dander _____________
Convulsions _______________ Rubella ___________
Food _________________
Diabetes __________________ Mumps___________
Insect Stings ___________
Bleeding/clotting Disorder_____ Mononucleosis______
Hay Fever _____________
Hypertension_______________ Asthma___________
Penicillin _____________
____________
Operations or serious injuries (specify dates):______________________________
______________________________________________________________________________
Disability or chronic recurring illness:___________________________________
Taking any medications Y/N ______________________________
Will they be taken during the camp program Y/N Instructions___________________
Any specific activities to be encouraged or limited by physician’s advice:
________________________________________________________________
_______________________________________________________________________________
Dietary Modifications:_____________________________________________________
Food allergies or
intolerances:_______________________________________________________
Name of
Physician:______________________________Phone:_____________________
Date of last physical exam:________ Medical insurance carrier:_________________
This health history is correct so far as I know, and the child described has permission to engage in all program activities
except as noted above. Emergency authorization: I hereby give permission to the medical personnel selected by the
Program Director to order x-rays, routine tests and treatment for my child, and in the event I cannot be reached in an
emergency, I give permission to the physician selected by the program director to hospitalize, secure proper treatment
for, and to order injection and/or anesthesia and/or surgery for my child as named above. Parent/Guardian
Signature: ____________________________________
THIS SIDE MUST BE COMPLETED AND SIGNED BY PHYSICIAN
Please record date of basic immunization and most recent booster:
Vaccine
Date of basic immunization
Date of Booster
_______ or_______________________________________________________________________________________________________ Tetanus Diphtheria
__________or________________________________________________________________________________________________________ Tetanus _________________________________________________________________________________________________________ Oral Polio (Sabin) TOPV
_________________________________________________________________ ______________ _______________________________________________________ Measles_______________________________________________________ Mumps _____________________________________________________________ Rubella (German measles) __________________________________ Other ________________________________________________________________ Tuberculin test given
_______________________________________________________________________________________________________________________
Health examination by licensed physician:
I have examined camp program applicant: ____________________________________________________ Date_____________________
child’s name
The child’s health does __________ does not ___________ preclude participation in an active camp program.
The child is under the care of a physician for the following condition(s) _______________________________________________________________
_________________________________________________________________________________________________________________________________________________
Current treatment (including current medications)_____________________________________________________
____________________________________________________________________________________________
Does child have a seizure disorder?________________________ Diabetes?_____________________________
Recommendations and restrictions while at Camp Program:
Any treatment to be continued at camp program: _____________________________________________________________________________________
Any medication to be administered at program (specify drug and dosage): _________________________________________________________
______________________________________________________________________________________________________________________________________________
Any dietary restrictions: __________________________________________________________________________________________________________________
Any allergies (food, drugs, plants, insects, animals, etc) ________________________________________________________________________________
Physician’s signature______________________________________________________________________________________Date___________________________
Physician’s name: ______________________________________________________________________________________Phone #__________________________
Please Note: An actual copy of the patient’s immunization records or check up evaluation can be used instead of this page.
The Berkshire Humane Society does not accept camper health records through the internet.
Source: http://briancabral.name/berkshirehumane.org/wp-content/uploads/2009/01/health_form_09.pdf
IVG PAR AUTO-ADMINISTRATION DE MISOPROSTOL: INTRODUCTION Depuis l’arrivé sur le marché de la mifépristone, autrement appelé la RU 486, vers la fin des années 1980, des millionsde femmes partout dans le monde ont fait des interromptions de grossesse sans risque à l’aide de ce médicament. Aucours des 20 dernièresannées, des études ontidentifiées plusieurs schémas d’avortement
THE EFFECT OF CULTURE CONDITIONS ON TOXICITY OF 6-MERCAPTOPURINE TO CHLORELLA VULGARIS Department of General and Analytical Chemistry, Medical University of Silesia, Faculty of Pharmacy, Jagiellonska 4, 41-200 , Sosnowiec, Poland e-mail: [email protected] The thiopurine antimetabolite 6-Mercaptopurine (6-MP) is an analogue of the purine base hypoxanthine and is indicated for