Home_Health_Questionnaire

NATURE’S CLASSROOM

HOME AND HEALTH INFORMATION QUESTIONNAIRE

Child’s Name__________________________ Date of Session____________________

The questions below are provided to give you a framework within which to provide that needed information to us. Please feel free to add whatever information you think will be helpful and attach an additional page if necessary. We will share this information with your child’s classroom teachers prior to his/her arrival at camp. Thank you for your cooperation.

Is this your child’s first prolonged stay away from home? _____yes _____no

Is this your child’s first sleep away experience? _____yes _____no

Has your child ever had a problem with homesickness?

_____yes _____no (If yes, please explain briefly.)_______________________

__________________________________________________________________

Does your child have a bed-wetting problem? _____yes _____no

*Date of your last tetanus booster shot (not a tetanus shot given after an injury).

*Required-Check with school nurse if unsure of date.

_____________________________

Are there any restrictions on your child’s activities? _____yes no_____

Please include any special health concerns, e.g.; special diet, recent hospitalizations, fractured bones, etc.

__________________________________________________

List any allergies, e.g.; food, environmental, medication and explain degree of severity and current treatment. _________________________________________

_______________________________________________________________

Has anything happened recently in your child’s life that may affect him/her emotionally or physically while at camp?

_____yes _____no (If yes, please explain.) ____________________________

_______________________________________________________________

Does your child sleepwalk or talk? _____yes _____no

Additional information: _________________________________________________

________________________________________________

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