Online Health Form Health Form Camp Jotoni Health FormPlease fill out all required fields.Camper Name* First Last Parent / Guardian Email* Date of Birth* Home Address* Street Address City State / Province / Region ZIP / Postal Code Gender* Male Female Health Insurance InformationIs the camper covered by family medical / hospital insurance?* Yes No if Yes, please indicate insurance carrier name*if Yes, please indicate insurance group number*Upload Copies of insurance cardsIf possible, please upload copies of your insurance cardsAllergy InformationDoes Your Camper Have Medication Allergies* Yes No If Yes, what medications? Please also list the reaction and treatment*Does Your Camper Have Food Allergies* Yes No If Yes, what medications? Please also list the reaction and treatment*Does Your Camper Have Other Allergies* Yes No If Yes, what medications? Please also list the reaction and treatment*Over The Counter MedicationsHeadache / Pain*Please Indicate the medication and dosageDiarrhea*Please Indicate the medication and dosageCough*Please Indicate the medication and dosageSore Throat*Please Indicate the medication and dosageCongestion*Please Indicate the medication and dosageMenstruation CrampsPlease Indicate the medication and dosageOtherPlease Indicate the medication and dosageGeneral Health QuestionsHas Your Camper...Had any recent illness or infectious disease?* Yes No If Yes .. Please explain*Have a chronic or recurring illness/condition?* Yes No If Yes .. Please explain*Ever been hospitalized?* Yes No If Yes .. Please explain*Ever had surgery?* Yes No If Yes .. Please explain*Have frequent headaches?* Yes No If Yes .. Please explain*Ever had a head injury?* Yes No If Yes .. Please explain*Ever been knocked unconscious?* Yes No If Yes .. Please explain*Wear glasses contacts or protective eyewear* Yes No Ever had frequent ear infections?* Yes No If Yes .. Please explain*Ever had seizures?* Yes No If Yes .. Please explain*High Blood Pressure?* Yes No If Yes .. Please explain*been diagnosed with heart murmur?* Yes No If Yes .. Please explain*Ever had back problems?* Yes No If Yes .. Please explain*Ever had problems with joints (e.g., knees, ankles)?* Yes No If Yes .. Please explain*Have an orthodontic appliance?* Yes No If Yes .. Please explain*Have any skin problem?* Yes No If Yes .. Please explain*Have diabetes?* Yes No If Yes .. Please explain*Have asthsma?* Yes No If Yes .. Please explain*Had mononuceosis in the past 12 months?* Yes No If Yes .. Please explain*Had chronic problems with diarrhea / constipation?* Yes No If Yes .. Please explain*Have problems with sleepwalking?* Yes No If Yes .. Please explain*Ever had emotional difficulties where professional help was sought?* Yes No If Yes .. Please explain*Please upload immunization recordsCAPTCHA