SayPro Medical History Form Template: A document template where participants provide relevant health information

Here is a SayPro Medical History Form Template that captures essential health information to ensure participants’ safety during the camp:

SayPro 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 SayPro 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 SayPro 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.