Camp Checkup

 

Child's name ______________________________________________

I performed a complete physical examination on this patient
on ________________.

Medical problems:

___________________________________________________________

___________________________________________________________

___________________________________________________________


___ This child is not contagious for any infectious diseases.


This child's allergies are: _______________________________

___________________________________________________________


This child's medications are: ______________________________

____________________________________________________________


___ This patient can participate in all sports and
    activities  OR

___ This patient should have limited activity as follows:

____________________________________________________________

____________________________________________________________


___ This patient can eat a regular diet  OR

___ This patient has the following dietary restrictions:

____________________________________________________________

____________________________________________________________


Physician's name ___________________________________________

Physician's signature _____________________ Date ___________

Physician's phone number ____________________________