Fillable Additional Health Information & Epi-Pen Form Medical Conditions/Behavioral (Lake Havasu City)

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Additional Health Information & Epi-Pen Form Medical Conditions/Behavioral (Lake Havasu City)

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The Additional Health Information & Epi-Pen Form Medical Conditions/Behavioral (Lake Havasu City) form is 2 pages long and contains:

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File type: PDF

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Rev. 6.30.15
Additional Health Information & Epi-Pen Form
Participant Name: _________________________________________________________
Health Insurance Provider: _______________________________ Plan or Group # ______________________________
Participant’s Physician: __________________________________ Phone: ______________________________________
Medical Conditions/Behavioral Issues
Does the Participant suffer from Asthma?
Yes
No
If yes, is the Participant’s asthma exercise induced?
Yes
No
Does the Participant carry a rescue inhaler?
Yes
No
Has the Participant been diagnosed with Hypertension?
Yes
No
Has the Participant been diagnosed with Diabetes?
Yes
No
Has the Participant been diagnosed with Epilepsy/Seizures?
Yes
No
Has the Participant been diagnosed with Heart Disease?
Yes
No
Does the Participant wear prescription eye glasses or contacts?
Yes
No
Does the Participant have any behavioral issues?
Yes
No
If yes, describe the behavioral issue, triggers, and suggestions for assisting Participant:
Has the Participant been diagnosed with any other medical conditions not listed above?
Yes
No
If yes, describe the medical conditions: _______________________________________
Please list any medication the Participant is currently taking and why:
_______________________________________
(Attach Additional Sheet if Necessary)
Allergies
Does the Participant have any life threatening allergies? (food, medication, plants, animals, insects, etc.) Yes ______ No _______
Participant’s anaphylaxis triggers are:
_____ Peanuts ______ Nuts _____ All Dairy ______ Eggs ______ Shellfish _____ Fish
_____ Food Additives, list: _________________________________________________________________________
_____ Insects/Bites, list: __________________________________________________________________________
_____ Medications, list: ___________________________________________________________________________
_____ Other, list: ________________________________________________________________________________
Participant’s anaphylaxis symptoms usually are:
____ Swelling (eyes, lips, face, tongue) ____ Coughing/Choking ____ Difficulty Breathing/Swallowing ____ Vomiting
____ Stomach Cramps/Diarrhea ____ Flushed Face/Body ____ Dizziness/Confusion ____ Change of Voice
____ Fainting/Loss of Consciousness ____ Cold, Clammy, Sweaty Skin ____ Other, list ____________________________
Participant’s emergency treatment is:
____ Anti-Histamine (list precise measuring instrument, specific brand, and dosage): __________________________
____ Epi-Pen Other, list: ________________________________________________________
Rev. 6.30.15
EPI-PEN REQUIREMENTS:
(initial after each of the below listed requirements)
- Participant must provide the program with two, non-expired Epi-Pens
(initials)
_________
- Epi-Pens must be in original container with appropriate label intact
(initials)
_________
- Participant must be trained to administer an Epi-Pen without assistance
(initials)
_________
Epi-Pens Expiration Dates: ____ / _____ / _____ ____ / _____ / _____
Number of times the Participant has used an Epi-Pen: _____________ Date of last use: _____ / _____ / ______
In the Event of an Anaphylactic Reaction:
1. Staff/Program Instructors may provide assistance to the Participant as he/she injects him/herself. Note:
Staff/Program Instructors are not trained medical professionals, but have completed the Standard First Aid
Training and will assist to the best of their ability.
2. Staff/Program Instructors will call 9-1-1 immediately to have an ambulance come to the program/event site.
3. Staff/Program Instructors will call parent/legal guardian/emergency contact to inform them of the incident and to
inform them the Participant is being transported by emergency personnel to the hospital.
Epi-Pen Waiver
(Only if Participant requires an Epi-Pen on-site)
I release Lake Havasu City, and its officers, directors, employees, independent contractors, and volunteers from any and
all liability arising out of or in connection with the decision to administer or not administer or to assist with the
administration of epinephrine.
I agree to indemnify and hold harmless Lake Havasu City, and its officers, directors, employees, independent contractors,
and volunteers of and against any and all liability, damage, claim, demand, cost, and expense (including without
limitation of attorney’s fees) arising out of or in connection with the use or non-use of an Epi-Pen for Participant and any
action, claim, or other legal proceeding brought against Lake Havasu City by a parent/legal guardian/spouse/family
member who has not signed in agreement.
Participant/Parent/Legal Guardian Signature: ______________________________________________________________
If Parent or Legal Guardian Printed Name: _________________________________________________________
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Additional Health Information & Epi-Pen Form Medical ConditionsBehavioral (Lake Havasu City)

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Completed 23 January 2021

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