Please Complete: Health and Behavior Form

Health and Behavior Form

Page 1

This Document Must be Completed by a Parent/Guardian if the Participant is Under the Age of 18

OVERVIEW

At VISIONS, it is our goal to provide an impactful and successful experience for each participant. To support that goal, and to benefit the wellbeing of the participant, it is imperative that all health and behavior information is fully disclosed. A participant will not be registered in a program until this form has been submitted and reviewed by a VISIONS representative. Please note the following:

In some cases, we cannot accept participants with conditions or situations that are incompatible with a program. We want everyone to have access to our programs, and we make all reasonable accommodations toward that end. Nonetheless, some situations require us to deny acceptance, including:

In-patient hospitalization or treatment in the last 12 months from program start date for:

Suicidal ideation/gestures/attempts
Eating disorders
Substance addiction
Violent behavior/legal issues
Active self-injurious behavior
Other mental health hospitalizations

Severe or unstable medical conditions such as seizures, diabetes, and cardiac disorders.
Ongoing concussion symptoms, repeated concussions, or traumatic brain injury within 6 months of program start date.

Living in a foreign environment may create unexpected physical and emotional stress, which may exacerbate otherwise mild conditions. Full disclosure will allow program leaders to be better prepared, and to facilitate a safe and successful experience.
We may require a signed mental health release form, and/or a signed physician release form, and/or a participant action plan for some health and behavior conditions. The VISIONS office will let you know if additional forms are required.
Please contact the VISIONS office before the program start date if there are any changes or updates in health, behavior, or medications.

GENERAL HEALTH

Participant's Name

Height

example: 4'10"

Weight

example: 130

General Health and Behavior Conditions:
Check all of the conditions below that the participant has been diagnosed with or has exhibited signs of. Conditions can have a bearing on health during the program, and leaders need to be equipped with the background information. Please consider each item carefully.

AcneActive Treatment For Cancer, Including Solid Tumors And LeukemiaADD, ADHDAnxietyAutism SpectrumBleeding or Clotting Disorders, DVTBullying (Bully or Bullied)Cardiac Illness or Significant Risk FactorsCirculatory IssuesCompromised Immune SystemConnective Tissue Disorders Such As Marfan’s Syndrome Or Osteogenesis ImperfectaConvulsions, SeizuresDepressionDiabetesEating DisorderFaintingFrequent Ear Infections or Hearing ImpairmentGastrointestinal DisturbancesGender Identity ChangesGrowth Hormone TreatmentHeart Defect/DiseaseHeat Stroke, Heat-Related ReactionsHypertensionHyperthyroid Or Hypothyroid ConditionsJoint or Musculoskeletal IssuesKidney Disease, Either Present At Birth Or Acquired LaterLearning Disabilities Or Other Cognitive ChallengesMenstrual Issues (heavy flow, strong cramps, etc)Migraines, Frequent HeadachesMononucleosis in past six monthsNeurological Problems, EpilepsyOther Concerns Raynaud’s DiseaseSelf Harm (Cutting, for example)Sleepwalking, Sleep DisordersSubstance Abuse, Chemical Dependency, Tobacco, Smoking, or Nicotine UseSuicidal IdeationWeight Issues (significantly over or under weight)

Please explain anything marked above, providing relevant dates where necessary.

List any surgeries or serious injuries, including dates and descriptions.

List any concussions, unconsciousness, or head injuries, including dates, causes, duration of unconsciousness, and any ongoing symptoms.

List any chronic or recurring illnesses, medical conditions, or diseases.

Provide details of any past communicable diseases, such as measles, mumps, Hepatitis, tuberculosis, whooping cough, or other.

Allergies

Does participant have any allergies (drug, food, environmental, or other)?

YesNo

Does participant have any systemic reactions to insects or bee/wasp stings (i.e.: swelling, rash, or difficulty breathing)?

YesNo

Is an EpiPen required for any allergy? (Note that VISIONS does NOT provide EpiPens on programs)

YesNo

Is the participant allergic to sulfa drugs? (Diamox and other sulfa drugs are sometimes used to treat altitude sickness)

YesNo

If yes to any of the above, please provide a list of the allergy, reaction, and treatment

Please provide any additional information regarding allergies, or note any suspected allergies that are not listed above. Important: Participants with known or suspected moderate to severe must bring an EpiPen. VISIONS does not provide EpiPens.

Asthma/Respiratory Problems

Does the participant have any past of ongoing asthma or respiratory problems?

YesNo

VISIONS requires all participants with asthma or respiratory issues to bring with them the medications and associated devices (i.e.: inhaler, nebulizer, spacer, etc.) for all status levels, including: daily (green), caution (yellow), and emergency (red). We recommend bringing multiple emergency inhalers, depending on the severity of the case.

List any triggers and symptoms, along with associated medicines, dosages, and steps to take in the case of distress. You also may provide VISIONS with the participant’s asthma action plan (visit the CDC website for examples: http://www.cdc.gov/asthma/tools_for_control.htm)

Has the participant been hospitalized as a result of asthma or respiratory problems?

YesNo

Please provide the dates of and reason for hospitalization

Food/Diet

Does the participant have any dietary restrictions not relating to allergies?

YesNo

Please provide details, including the specific restrictions and if the reasons are religious, medical, or other

Physical Restrictions

Does the participant have any physical limitations that require consideration or assistance?

YesNo

Does the participant have any cognitive or sensory conditions that require consideration?

YesNo

Does the participant have any activity restrictions?

YesNo

Please provide details, including the specific restrictions and/or considerations

Mental Health

Prior to acceptance, participants with a history of psychotherapy must be medically stable. VISIONS is not appropriate for applicants who have just completed a residential treatment program.

In the past or currently, has the participant received psychotherapy? (Providers include, but are not limited to: psychiatrist, psychologist, social worker, counselor)?

YesNo

Please explain, and include dates, reason for therapy, and treatment

Behavior

VISIONS is not a program for youth at risk, and inappropriate placement can be detrimental to the participant and to the program. Behavior issues are subject to reprimand and can lead to dismissal from the program without refund.

Has the participant ever been suspended from school, had chronic behavior issues, or received disciplinary action related to drugs, alcohol or crime?

YesNo

Please explain, and include date, details, and any disciplinary action taken

Additional Information

Date of the participant's last tetanus shot. It is required that all VISIONS participants have had a tetanus shot within the last 10 years.

Does the participant see a medical or physical specialist of any kind that has not been previously noted?

YesNo

Please provide details, including the name of the specialist and the reason for seeking treatment

Does the participant have any condition or limitation (physical, mental, emotional) that has not been previously disclosed, which may affect their wellbeing, the wellbeing of others, or their ability to engage in program activities?

YesNo

Please provide details on any other condition or limitation

What is the participants swimming ability?

Non-SwimmerPoorCompetentAdvanced

Please let us know if there are concerns about the participant in water-based activities, or if the participant has a fear of the water.

Medication

Will the participant be bringing any prescribed medications?

YesNo

List all medications that your child will take to the program, what they are used to treat, and the precise dosage. Note that participants can only bring the exact dosage of medication needed for the program.
All participants will carry and administer their own medications and must understand how to responsibly use and administer their medications, per their physicians instructions.
*A participants misuse of any medication will be grounds for dismissal from the program.

Include:

- Medication
- Dosage and frequency
- Used to treat
- Common side effects/effects of a missed dose
- If medication requires refrigeration or injection

Prescribed medications that will be taken during the program:

Contacts and Insurance

First Emergency Contact
(OTHER THAN PRIMARY PARENT/GUARDIAN)
*PLEASE DO NOT INCLUDE MOTHER OR FATHER*

Name

Phone 1

Relationship to participant

Phone 2

Second Emergency Contact
(OTHER THAN PRIMARY PARENT/GUARDIAN)
*PLEASE DO NOT INCLUDE MOTHER OR FATHER*

Name

Phone 1

Relationship to participant

Phone 2

Medical Providers
(This section is optional)

Primary Care Physician

Physician Name

Physician's Phone Number

Name of Practice

Dentist

Dentist Name

Dentist's Phone Number

Name of Practice

Other Medical Provider (ex: psychotherapist)

Name of Provider

Other Phone Number

Other Practice Name

Other Field of Practice

Health Insurance

Policy Holder Name and Address

Insurance Company Name

Policy Number

Group Insurance Name
(employer, union, association, or n/a)

Group Policy Number

Insurer Address

City

State

Postal Code

I hereby swear that I have completed this form with comprehensive, accurate, and truthful information about myself or my child. I understand that failing to provide information is grounds for program cancellation or dismissal without any reimbursement. Prescribed medications, including EpiPens for allergic reactions, will be sent with my child for the program or I will bring them with me. I will contact the VISIONS office immediately if there are any medical or behavior updates after submitting this form. Signing this form (digital or otherwise) signifies agreement with all of the above, and is binding.

I Agree

Signature (typed)

* PLEASE NOTE THAT THE HEALTH AND BEHAVIOR FORM WILL NOT BE MARKED COMPLETE UNTIL THE OFFICE HAS REVIEWED AND ACCEPTED IT (THIS USUALLY TAKES A FEW DAYS). IF THERE IS SOMETHING ON THE FORM THAT THE OFFICE FEELS NEEDS FURTHER ATTENTION, WE WILL BE IN TOUCH. THANK YOU!

Contact Information