Sickle Cell Disease Form printable pdf download

Camper Name: ___________________________________________________________________

Birthdate: ____________________________

SICKLE CELL DISEASE FORM

TO BE COMPLETED BY A LICENSED HEALTH CARE PROVIDER

This form, in addition to the Physical Exam form, must be completed by

medical provider for all applicants.

Specialty MD ___________________________________ Day Phone _________________________ After-Hours Phone _________________________

Address ________________________________________________________ Email _____________________________________________________

Hospital (where child is treated):______________________________________ Nurse/Coordinator:__________________________________________

What hemoglobinopathy does the child have? (SS,SC, etc.) ______________________Baseline room air saturation____________________________

Does the child require O2 for sleeping?

□ No □ Yes

If YES, what is the rate?________________________________________________

Medical complications/events in the last year:___________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

Does this child have any chronic abnormal physical findings?____________________________________________________________________________

Is the child on a chronic transfusion protocol?

□ No □ Yes If yes, how frequently?________________________________________________

Does the child have a central venous catheter?

□ No □ Yes

If yes, please complete the CV Catheter form. (Please contact Camper Recruiter if you do not have this form).

Accommodations at camp:

⧠ Use standard Roundup River Ranch camp accommodations for campers with sickle cell disease (contact us for a complete list)

This camper has retinopathy. DO NOT USE NSAIDS (non-steroidal anti-inflammatory medications)

⧠

This camper has additional special accommodations:________________________________________________________________________________

⧠

Please provide most recent labs or attach clinic note

Date of labs:___________________________________________________

Hgb/Hct:__________________________ Retic:___________________

WBC:_______________________

Pain Protocol:

What does this child take for mild pain?_________________________________________________________________________________________________

Moderate Pain?________________________________________________________________________________________________________________________

Severe Pain?___________________________________________________________________________________________________________________________

____________________________________________

__________________________

________ _________________

Name of MD, NP, PA (Print)

Signature

Date

____________________________________________

___________________________

_______ _________________

Completed by (Print Name)

Signature

Date

Please fax the completed form to ( 888) 524-2477 or email to

Sickle Cell Disease Form

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