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 ____________________________