Medical Form for Children: Family Respite Laurentides-Lanaudière-Outaouais

Name of the family

Ex.: Côté-Tremblay

General Information

Name*

First name Last name

Home phone*

Date of birth*

Gender*

M
F
Other

Age at Respite*

Health insurance number (without spaces)*

Expiration date*

Email

Legal Guardian

Name*

First name Last name

Relationship*

Emergency contact on site

Name

First name Last name

Phone

Emergency contact (out of the Family Respite site)

Name

First name Last name

Relationship

Phone

Medical Informations

Please indicate who you are filling out the form for*

Child with cancer
Other child who does not have cancer

Diagnosis*

Date of diagnosis*

Date of relapse

Date of remission

End of treatment date

Date of marrow transplant

Type of transplant

Vaccines

Has your child received a tetanus vaccine since 2012?*

Yes
No

Has your child received the chicken pox vaccine?*

Yes
No

Has your child had chicken pox?*

Yes
No

Illnesses

Does your child suffer from or is he or she affected by:

Skin problems?*

Yes
No

If yes, provide details:

Vascular problems?*

Yes
No

If yes, provide details:

Heart disease (hypotension, hypertension, infarct, etc.)?*

Yes
No

If yes, provide details:

Respiratory problems/Asthma?*

Yes
No

If yes, provide details:

Diabetes?*

Yes
No

If yes, provide details:

Joint/ bone problems?*

Yes
No

If yes, provide details:

Recent trauma/ fracture?*

Yes
No

If yes, provide details:

Mobility problems?*

Yes
No

If yes, provide details:

Does he use a walking aid (wheelchair, cane, other)?*

Yes
No

If yes, provide details:

Does he need help with activities of daily living?*

Yes
No

If yes, provide details:

Does he wear prostheses/orthotics?*

Yes
No

If yes, provide details:

Recent surgery (less than 6 months)?*

Yes
No

If yes, specify the nature of the intervention and the date :

Has he received antibiotics in the last six months?*

Yes
No

If so, for what reason.

Special diet, including gastrostomy, feeding tube or a particular milk?*

Yes
No

If yes, provide details:

Does your child have a central line ? (PICC line, PAC, other)*

Yes
No

If yes, provide details:

Language or communication problems?*

Yes
No

If yes, provide details:

Attention deficit troubles, with or without hyperactivity?*

Yes
No

If yes, will your child take medication during camp?

Does your child have a visual and/or hearing limitation*

Yes
No

If yes, specify

Other health problems: (check and specify)

Headaches
Cold sores (cold sore)
Stress/Anxiety
Depression
Insomnia
Epilepsy
Ear infections
Athlete's foot/Plantar warts
Other

Specify

Allergies and intolerances

Allergies?*

Yes
No

Medications?*

Yes
No

If yes, provide details:*

Food?*

Yes
No

If yes, provide details:*

Other allergies?*

Yes
No

If yes, provide details:*

Is an Epipen needed?*

Yes
No

Diet

Check and specify

Kosher/Hallal
Pork-free, gelatin-free
Vegetarian
Vegan/Vegan
Lactose free
Gluten-free
Gavage Nasogastric tube or stoma?
Other

Specify

Please add any details, lifestyle issues or conditions that might help us to know and understand you better. Together, we can ensure that you get the most out of your stay.

Medical Form for Children: Family Respite Laurentides-Lanaudière-Outaouais

Medical Form - Family Respite Laurentides-Lanaudière-Outaouais 2022 - Children

General Information

Legal Guardian

Emergency contact on site

Emergency contact (out of the Family Respite site)

Medical Informations

Vaccines

Illnesses

Allergies and intolerances

Diet

Partners