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2024 Physical and Medication Form 1

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Brooke Elzey
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15 views2 pages

2024 Physical and Medication Form 1

Uploaded by

Brooke Elzey
Copyright
© © All Rights Reserved
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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IdRaHaJe

PHYSICAL Camper Name:


FORM (Due 1 week before camp)
Camp & Week Attending:
Year:

CAMPER’S PHYSICAL FORM: To be filled out by the doctor

Medical condition(s) Camp should be aware of:


Special instructions (e.g., special diets, exempted activities, etc.):
Allergies (e.g., drugs, food, other):
Camper's biological sex: M / F
Does this camper regularly take prescription medications, OTC medications, or vitamins? Yes / No

(If yes, please fill out the attached Medication Form with correct dosage and frequency)
was given a camp physical examination on / / . (Must be within 24
months of designated Camp.) S/he is in satisfactory physical condition and capable of active participation except as noted above.

Signature of Doctor Date Phone ( )

Printed Name Address City State Zip

PRN Prescription for OTC Medications: To be filled out by the doctor


Must be completed by prescribing health care professional.
Physicians: Please initial each medication and dosage that you approve and prescribe PRN.
**If the child has prescribed medications or requires changes to the following medications, please fill out the attached
Medication Form.
This camper may receive the following OTC medications and dosages:
Zyrtec (Cetirizine) or Claritin (Loratadine) - 10 mg q24h PRN for itching/seasonal allergies
Benadryl (Diphenhydramine)- 12.5-25mg q4-6h PRN for itching/allergic reaction
Chlor-tab (Chlorpheniramine)- Children 6-12 yr: 2mg q4-6h PRN; Children >12 yr: 4 mg q4-6h PRN for itching/seasonal
allergies/ allergic reaction
Tylenol (Acetaminophen)- 15mg/kg q4-6h PRN for fever and/or pain
Motrin (Ibuprofen)- 10mg/kg q6h PRN for fever and/or pain
TUMS (Calcium Carbonate)- 500-1,000 mg/day PRN for upset stomach/indigestion
Throat Lozenges- 1 lozenge q3-4h PRN for sore throat and/or cough
Triple Antibiotic Cream- 1 application PRN for cuts/scrapes

Signature of Doctor Date Phone( )

Printed Name Address City State Zip


Camper Name:
IdRaHaJe Camp & Week Attending:
MEDICATION Year:

FORM (Due 1 week before camp)


This form must accompany all prescriptions, OTC medications, homeopathic remedies, essential
oils and vitamins in their original container and box and must include the signature of the child’s
doctor.
_____________________________ _______________________________ ___________
Parent/Guardian Printed Name Signature Date

NOTES: CAMP MEDICAL STAFF SIGNATURE:

x
DOCTOR MUST LIST ALL MEDICATIONS BELOW, INCLUDING: PRESCR., OTC, VITAMINS, ETC.

LIST Rx: eg.Clarinex D tab SUN MON TUE WED THU FRI
PERSONNEL↓
↓CAMPPERSONNEL↓

Med:
Dosage/Route: 8am
Time: 12pm
↓CAMP

To Treat What? 6pm


Contraindications: Bedtime

LIST Rx: eg.Clarinex D tab SUN MON TUE WED THU FRI
PERSONNEL↓
↓CAMPPERSONNEL↓

Med:
Dosage/Route: 8am
Time: 12pm
↓CAMP

To Treat What? 6pm


Contraindications: Bedtime

LIST Rx: eg.Clarinex D tab SUN MON TUE WED THU FRI
↓CAMP PERSONNEL↓

Med:
Dosage/Route: 8am
Time: 12pm
To Treat What? 6pm
Contraindications: Bedtime

PRESCRIBING DOCTOR’S SIGNATURE:


x Date Phone ( )
Printed Name Address City State Zip

Please use additional forms if necessary.

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