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Ano:n ast)ma
triggers
6sua' s*mptoms o%
ast)ma
8orsening s*mtoms
)%ercise 7hee>ing 7hee>ing
&oldsVirus -ightness in chest -ightness in chest
Pollens &oughing &oughing
*ust *ifficulty =reathing *ifficulty =reathing
;ther# *ifficulty Spea+ing *ifficulty Spea+ing
;ther# ;ther#
/s preventative medication used regularly,
*oes the participant always carry the medication with them,
*oes the participant need assistance ta+ing their medication,
ame o% Ast)ma
medi(ation
Met)od Dosage= %re-uen(* $ timing
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A772R4IC R2AC5I, MAA42M25
'ave you ever suffered an allergic reaction to#
/nsect bites
Plant Pollen
*etergents or cleaning agents
!ood groups or additives
-o%ins
;ther triggers 99999999999999999999999999
I% *ou )a!e ti(;ed an* o% t)e a1o!e= t)en it is re-uired t)at *ou %i'' in t)e neBt
se(tion o% t)e A''ergi( Rea(tion Management<
See+ the advice of your medical practitioner if necessary when completing this form.
7hat are the triggers allergens that your child is allergic to,
7hat are the signs and symptoms of the reaction,
'as your child at any time suffered from? (5ICA appropriate bo%es)
5 localised reaction (any rash0 itching0 swelling at the site the poison has entered)
5 systemic reaction (any rash0 itching swelling away from the site where the poison has
entered)
5n anaphylactic reaction (severe breathing problems0 swelling of the body0 emergency
situation)
.=een hospitalised due to an allergic reaction,
/s adrenaline (e.g. adrenaline in8ection0 medi@epihaler0 epi@pen) administered when your child
suffers from an allergic reaction, Yes "o (Please circle one)
7hat medication does your child ta+e (if any) for prevention against an allergic reaction,
7hat treatment is followed for your child0 if an allergic reaction occurs,
5ll medication for the sufferers allergic reaction must firstly be noted on the medical form
and then brought on the camp by the participant and given to the camp leader.
I% *ou )a!e e!er eBperien(ed an anap)*'a(ti( rea(tion .se!ere 1reat)ing pro1'ems=
s:e''ing o% t)e 1od*= emergen(* situation/ or 1een )ospita'ised due to a''ergi(
rea(tion t)en *ou must (onsu't :it) *our medi(a' pra(titioner a1out *our
parti(ipation in t)is (amp prior to (omp'eting t)e registration %orm<
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