Medical Recommendations Form For Campers printable pdf download

MEDICAL RECOMMENDATIONS FORM FOR CAMPERS

PLEASE MAIL THIS FORM TO ADDRESS INDICATED ON INSTRUCTIONS BY MAY 1

. FORM TO BE COMPLETED BY MEDICAL PERSONNEL.

Name of Camper: ___________________________________________________________ Sex:  Female  Male

First

Middle

Last

Birthdate: __________ Age Upon Arrival at Camp: ______ Dates attending Camp: From __________ to __________

Month/Day/Year

Camper Home Address:

__________________________________________________________________________

Street Address

City

State

Zip Code

Parent/Guardian Phone Number: (______)________________________

STOP HERE. THE REST OF THIS FORM TO BE COMPLETED BY MEDICAL PERSONNEL

##########

. ##########

The following non-

MEDICAL PERSONNEL: Please review the HEALTH HISTORY FORM and

prescription medications are

complete all remaining sections of this Form, attaching additional information as needed.

commonly stocked in camp



Date of Last Physical: __________

Physical Exam Today:

Yes

Health Centers and are used

on as AS NEEDED basis to

Weight: _____lbs

Height: ____ ft ____in

Blood Pressure ____/____

manage illness and injury.

Allergies:

MEDICAL PERSONNEL:

_____ No known allergies.

Please CROSS OUT those items the



_____ Camper has an allergy to:

Food

Medicine

Camper should NOT be given.



Environment (insect stings, hay fever, etc.)

Other

Acetaminophen (Tylenol)

Please list allergies and describe previous reactions:

Ibuprofen (Advil, Motrin)

________________________________________________________

Chlorpheneramine maleate

Diet/Nutrition:

Guaifenesin



This Camper

Eats a Regular Diet

Has a medically prescribed

Dextromethorphan

meal plan or dietary restrictions. Please describe:

Diphenhydramine (Benadryl)

________________________________________________________

Generic Cough Drops

The Camper is undergoing treatment at this time for the

Chloraseptic (Sore throat spray)

following condition:

Please describe:

Lice Shampoo or scabies cream

________________________________________________________

(Nix or Elimite)

Medication:

Calamine lotion

_____ No daily medications

Hydrocortisone 1% cream

_____ Will take the following prescribed medication(s) while at camp:

Topical antibiotic cream

Please describe (name, dose, frequency):

Calamine lotion

________________________________________________________

Aloe

________________________________________________________

Other treatments/therapies to be continued at camp:

Please

describe:

___________________________________________________________

Do you feel that the Camper will require limitations or restrictions to activity while at camp:



Yes. Please describe: _________________________________________________________________________

I have reviewed the HEALTH HISTORY FORM and discussed the camp program with the Camper’s Parent(s)/Guardian(s). It is my

opinion that the Camper is physically and emotionally fit to participate in an active camp program (except as noted above).

Name of licensed provider (please print): ____________________________ Signature: ____________________Title: _______

Office Address: ___________________________________________ Telephone: __________________ Date: ______________

012616

Medical Recommendations Form For Campers

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