Physical Exam Form
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1
2Camper Name: ___________________________________________________________
Birthdate: ____________________________________
PHYSICAL EXAM FORM
TO BE COMPLETED BY A LICENSED HEALTH CARE PROVIDER
This two page physical exam form must be completed and signed by the child’s PCP or Specialty Doctor
NAME OF PHYSICIAN TO CONTACT
Primary Care Physician:
Specialist:
Email:
Email:
Address:
Address:
Day Phone:
Day Phone:
After Hours Phone:
After-Hours Phone:
PCP Hospital Affiliation:
Specialist Hospital Affiliation:
GENERAL INFORMATION:
Primary Diagnosis: ______________________________________________Date of Diagnosis:__________________________________________________
Please list current medical issues and/or secondary diagnoses: ______________________________________________________________________
___________________________________________________________________________________________________________________________________
Surgical History: ____________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Is this child immune to varicella?
No
Yes
If yes:
By immunization
Clinical disease (Date _____ )
Positive titers
Has this child had shingles?
No
Yes
If Yes, date__________
Drug Allergies: _____________________________________________________________________________________________________________________
Food Allergies: ____________________________________________________________________________________________________________________
Other Allergies (i.e. bees, horses, latex, mold, etc): __________________________________________________________________________________
___________________________________________________________________________________________________________________________________
PHYSICAL EXAM: Please list any pertinent physical findings or attach a recent history & physical.
Height: _________ Cm Weight: _________ Kg Blood Pressure _________ Pulse _________ RR _________ O2 Sat _________
Pertinent findings: __________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Physical disability or limitations affecting any camp activity:
No
Yes
If Yes, please explain, including use of braces, wheelchair, crutches, artificial limbs, or other mobility aids:
________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Is the child’s development appropriate for his or her age?
No
Yes
If No, at what age does child function? _____________________________________________________________________________________________
Are there any behavior problems that would affect child’s participation in a group?
No
Yes
If Yes, please describe: _____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Is there anything else you would like us to know about this patient? __________________________________________________________________
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Fax completed form to 888-524-2477 or email to
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