Campquestsc.org

PHYSICAL EXAM FORM
CAMPER INFORMATION
Camper’s Name__________________________________________Date of Birth: ______________________ Parent/Legal Guardian: Please complete the Camper Information section above and
provide this form and a copy of the camper’s completed Health History Form to your
child’s physician.
Physician: Please review the camper’s Health History Form and complete remaining
CURRENT HEALTH ASSESSMENT
Date of Camper’s Most Recent Physical Exam:  Today  Other date (please specify): ______
Height: ___________Weight:___________ Blood Pressure: _____ /_______Blood Type:________(if known) Is the camper undergoing treatment at this time for any medical conditions?  NO YES (if yes, please describe):________________________________________________________________________ ______________________________________________________________________________________________ Will the camper be taking any prescribed medications while at camp?  NO YES (if yes, please describe name, dose, frequency, and reason for each medication):____________________ ______________________________________________________________________________________________ Please list any allergies the camper has, including to medications, foods, environment allergens, animal allergens, etc. Please also describe the camper’s reaction to each
allergen. _____________________________________________________________________________________
______________________________________________________________________________________________ ______________________________________________________________________________________________
HEALTH HISTORY
Immunization history, including date of most recent tetanus shot: ____________________________ ______________________________________________________________________________________________ Has the camper undergone any surgeries or hospitalizations?  NO YES (please provides dates/reasons):______________________________________________________________________________________________ RESTRICTIONS AND RECOMMENDATIONS
Does the camper have any medical or health conditions that will require limitations or
restrictions on his/her activity while at camp?  NO YES If yes, please describe your
recommendations:
______________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________ Place a check mark next to any of the over-the-counter medications below which should
NOT be given to the child:
"I have reviewed the camper’s Health History Form and have discussed the camp program with the camper’s parent/legal guardian. It is my opinion that the camper is physically and emotionally fit to participate in an active camp program, except as noted above." Signature of Camper’s Physician:_____________________________Date:___________________________ Physician Name: ____________________________________________ Phone Number: (_____)__________ Address: _______________________________City:_____________________State:_________Zip:___________

Source: http://campquestsc.org/wp-content/uploads/2012/02/Physical-Exam-Form.pdf