Health Record Form For Children In Day Camps , Afterschool And Youth Centers Page 2

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PHYSICAL EXAMINATION
(To be filled out by Physician – please note information on reverse side)
The purpose of this health record is to provide the staff with pertinent information which will help to serve the needs
of this child in Day Camps and Afterschool and Youth Center programs.
IMMUNIZATION HISTORY – This is a record of dates of basic immunization and most recent booster doses.
DTaP, DTP, DT, Td
Date __________
Date __________
Date __________
Date __________
Date __________
Polio
Date __________
Date __________
Date __________
Date __________
Date __________
MMR
Date __________
Date __________
Date __________
Hemophilus Influenzae type b (Hib)
Date __________
Date __________
Date __________
Date __________
Hepatitis B
Date __________
Date __________
Date __________
Date __________
Varicella
Date __________
Date __________
Pneumococcal
Conjugate (PCV)
Date __________
Date __________
Date __________
Date __________
Date __________
Other _____________ Date __________
Other _________
Date __________
Other _________
Date __________
MEDICAL EXAMINATION – To be filled out by licensed physician.
Examination is acceptable when performed no more than 12 months prior to arrival at camp.
Code: S = Satisfactory
X = Not Satisfactory (Explain)
0 = Not Examined
General Appearance
Genitalia
Height
Weight
Blood Pressure
Posture & Spine
Throat - Tonsils
Nose
Teeth
Abdomen
Hernia
Feet
Lungs
Skin
Hgb. Test (Date)
Urinalysis (Date)
Eyes
Vision
w/Glasses
Extremities
Heart
Ears
Hearing
Neurological Findings
Describe Abnormal Findings and/or Handicapping Conditions
Allergy:
(Please specify)
Recommendations and restrictions while in camp:
Special Diet
Special Medicine (dose, route of administration, when should it be administered)
Is parent/guardian sending special medicine?
Activity Restrictions
Swimming
Diving
General Appraisal:
I have examined the person herein described, reviewed his/her health history and it is my opinion that he/she is physically able to
engage in Day Camp/Year Round Afterschool and Youth Center activities, except as noted above.
M.D.
EXAMINING PHYSICIAN (SIGNATURE)
PHYSICIAN'S NAME (PLEASE PRINT)
Telephone
Address
Date of Examination
ZIP CODE
DCR 7 (Rev. 2/04)

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