Health Care Questionnaire

(Please Print)

Name _________________________________________________________________________

Last First Middle Initial

Date of birth_____________________________ Social Security Number____________________

Street Address____________________________City______________________Zip___________

Each question below must be answered. Medical information is kept completely confidential. If

you have a serious medical condition requiring special care or medication, please include

a letter of instruction from your physician. This information would be required should medical

treatment be necessary while you are attending the Information Matrix Camp.

Are you taking any medication? o Yes o No If yes: o Over-the-counter o Prescription

List medication(s) that will be brought to the Camp: ____________________________________

______________________________________________________________________________

Dosage, frequency, and reason:____________________________________________________

______________________________________________________________________________

If prescription, list prescribing physician and his/her address:_____________________________

______________________________________________________________________________

All prescription medications must be brought in the original, properly labeled container

from your pharmacist.

Do you have a physical or psychological condition that the program director should be aware

of? o Yes o No

If yes, please explain:____________________________________________________________

Have you been hospitalized or seen by a medical doctor or chiropractor within the last 12 months?

o Yes o No

If yes, list date and reason:_______________________________________________________

Date of your last tetanus shot:________________________________

Are you allergic to any medication or drugs? o Yes o No

If yes, what?______________________________________________

Are there any other known allergies? o Yes o No

If yes, what?______________________________________________

Name of primary physician:________________________________________________________

Telephone: ( )__________________________City:__________________________________

Are you covered by medical insurance? o Yes o No

Name & address of insurance co.____________________________________________________

_______________________________________________________________________________

Name of insured:_________________________________________________________________

Insured’s Social Security number:____________________________________________________

Policy number:___________________________ Group number:___________________________

Medical Permission

The Oklahoma Library Association or Rose State College staff has permission, in case of a need

for medical attention, to provide any medical treatment deemed necessary in the judgment of camp

staff. Permission is also given to camp staff to transport me to any medical facility, if deemed by

camp staff to be medically feasible and/or necessary.

_______________________________________________________________________________

(Student Signature) (Date)

_______________________________________________________________________________

(Parent and/or Legal Guardian, if applicable) (Date)

Emergency contact: Day ( )_______________________Night ( )______________________