Dermatology Form
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1Camper Name: ___________________________________________________
Birthdate: ______________________________
DERMATOLOGY FORM
TO BE COMPLETED BY A LICENSED HEALTH CARE PROVIDER
This form, in addition to the Physical Exam form, must be completed by a specialty provider for all applicants.
Specialty MD ___________________________________ Day Phone _________________________ After –Hours Phone __________________________
Address ________________________________________________________ Email ____________________________________________________________
Hospital (where child is treated):______________________________________ Nurse/Coordinator:__________________________________________
Diagnosis:__________________________________________________________________Date of Dx:___________________________________________
Secondary Diagnoses:____________________________________________________________________________________________________________
Unique characteristics of skin disease:_____________________________________________________________________________________________
Serious Complications?
□ No □ Yes If yes, please provide details:___________________________________________________________
_________________________________________________________________________________________________________________________________
Does this camper have heat intolerance?
□ No □ Yes
Increased risk of injury from trauma?
□ No □ Yes
Osteoporosis or history of multiple fractures?
□ No □ Yes
Risk for bleeding?
□ No □ Yes
Immunosuppression precautions?
□ No □ Yes
Live vaccines deferred?
□ No □ Yes
Medically prescribed meal plan or dietary restrictions? □ No □ Yes
If yes to any of the above, please explain:_________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Are there any recommendations or limitations regarding this child’s activities while at camp?
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Any need for intensive supervision or assistance based on severity of condition?
_________________________________________________________________________________________________________________________________
Dressing Changes:
Type of dressing used:____________________________________________________________________________________________________________
Frequency of dressing changes:___________________________________________________________________________________________________
Frequency of baths:______________________________________________________________________________________________________________
Comfort measures or distraction techniques used during dressing changes._________________________________________________________
_________________________________________________________________________________________________________________________________
Laboratory: All campers with RDEB and JEB should have recent labs—please attach.
Please attach most recent clinic note
__________________________________________________
_________________________________
___________________________
Physician Name (Print)
Signature
Date
__________________________________________________
__________________________________
___________________________
Completed by (Print Name)
Signature
Date
Fax completed form to 888-524-2477 or email to
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