2022 YLC Staff Health Form To be completed by a staff member’s doctor/physician by June 1, 2022. Physical exams made before July 25, 2022 will not be accepted. If you have any questions about this form please email [email protected] with subject header "YLC Staff Completed Health Form".Name * Required First Middle Last Date of health exam - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Birthdate - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Gender * RequiredNon-binaryFemaleMaleHeight * Required Weight * Required Blood pressure * Required Hair color * Required Eye color * Required Please check if the staff member had any of the following health problems. If you checked yes, please explain the comment box provided below.Health History Information Allergies (Food, Drugs, Plants, Insects, etc.) Asthma (If yes, does he/she use an inhaler?) Back/Joint Pains Cardiovascular Disorders Cerebral Palsy Chicken Pox Clotting Disorders Diabetes Epilepsy/Convulsions Eye Infections Fainting Frequent Ear Infections German Measles Hemophilia Hernia Measles Meningitis Menstrual Problems Mumps Nose Bleeds Respiratory Infections Rheumatic Fever Severe Vision Problem Stomach/Intestinal Problems Urinary Tract Infections Vaginal Infections Mental Health Concerns (including ADHD, Depression, etc.) Major Surgeries Serious Injuries Physical Limitations Elaborate on any of the items checked above:Add any other history that is not listed above:Any chronic or recurring illnesses? * RequiredNoYesAdd info about chronic/recurring illnesses: * RequiredAny dietary requirements, restrictions, or allergies? * RequiredNoYesAdd dietary requirements, restrictions, or allergies: * RequiredHas the camper been exposed to anyone who is at risk for latent Tuberculosis infection or has TB disease? IF so - when was the campers last Tuberculosis test? - must be mm/dd/yyyy format MM slash DD slash YYYY Does the staff member carry an epinephrine pen? * RequiredNoYesFor what? * Required Any additional physical/mental health considerations?Is the staff member currently on medications? * RequiredNoYesPlease include drug name, route, dosage, and schedule. Please state what will happen, including onset behavior, if the staff member does not take the medicine. * RequiredImmunization History DPTPlease list ALL of your immunization shots including year(s) of immunization and last booster. (e.g. Tetanus/Diphtheria - shot 1998, booster 2008) Here's a list of typical shots: Tetanus/DiphtheriaTetanus (alone)Oral Polio (Sabin)Injectable Polio (Salk)Measles (Rubeola)Measles (Rubella)MumpsBy submitting this form, I certify that I have on this date examined the above named staff member and that on the basis of my examination and the medical history as furnished to me, I have found no reason that would make it medically inadvisable for this staff member to participate in physically strenuous activities.Licensed Physician's name * Required First Last Licensed Physician's address * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Licensed Physician's daytime phone number * RequiredLicensed Physician's emergency/evening phone number * RequiredSignature