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Physical Form

This document is a health disclosure form for a camper attending an upward bound summer camp. It requests information from the camper's physician about any relevant medical history including illnesses, injuries, immunizations, medications, and any recommendations or restrictions for camp activities. The physician must sign to confirm the camper is able to participate in camp activities with any noted exceptions and that their immunizations are up to date. The form also collects emergency contact information and confirmation that a liability waiver will be signed for the camper.

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22 views

Physical Form

This document is a health disclosure form for a camper attending an upward bound summer camp. It requests information from the camper's physician about any relevant medical history including illnesses, injuries, immunizations, medications, and any recommendations or restrictions for camp activities. The physician must sign to confirm the camper is able to participate in camp activities with any noted exceptions and that their immunizations are up to date. The form also collects emergency contact information and confirmation that a liability waiver will be signed for the camper.

Uploaded by

evanatubc
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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HEALTH DISCLOSURE FOR UPWARD BOUND CAMP ATTENDANCE

FOR PHYSICIAN TO COMPLETE: Please indicate ANY history of the following:


Date of this examination Date of last physical Polio Fainting Sinus trouble Convulsions Circulation Problems TB Hernia Appendectomy Chicken Pox Bleeding/clotting disorder Mumps Herpes Hepatitis Carrier Tubes in ears Urinary/GI track problems Measles Asthma Whooping Cough Stomach trouble Ear infections/aches Heart defect/disease Type: Is camper currently under the care of a physician for chronic conditions? Y N Explain: Is camper currently under the care of a dentist/orthodontist? Y N Explain: Is patient under the care of a mental health specialist? Y N Explain: Has the camper had any serious injuries/bone breaks/or operations in the past? Y N Explain

Describe nature of present disability if known: Date of last Tetanus Toxoid:___________ Are Immunizations Current? Y N

Indicate significant findings/conditions: Height Ears Extremities Abdomen Nose Heart Genitalia Throat Spine Lungs

Weight Legs

BP

Eyes Feet

Skin/Scalp __ Other observations:

General Disposition

Recommendations/Restrictions while at camp: Medications Presently Prescribed (use additional sheets if necessary) Medication Route/Dose/Time Pharmacy

Prescription #

Purpose

PRNS List any additional medication AUTHORIZED for administration (i.e. headaches, insect bite, allergic reactions, etc) Medication needs in Emergency Camp activities may include, but not be limited to, choices of swimming, nature hikes, paddle boating, horseback riding, fishing, field games, board games, bowling, mini-golf, cooking out of doors, crafts, drama, music and dancing. I have examined the person herein described and have reviewed the health history information provided above. It is my opinion that this camper is physically able to engage in camp activities, except as noted above. Physicians Signature Date Physician Name Printed Mail Address or PO Box City State Zip Phone

Important: A liability release and release to obtain emergency intervention must be signed by guardian prior to attendance. If camper is not own guardian, the guardian must be consulted prior to pre-registration for approval to attend. Is camper own guardian? Y N If no, list Guardian name: Parent/Guardian Name Printed Phone Address /PO Box Email ______________________________

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