Health exam

2009 Kamp Kiwanis®
Health Exam by a Physician
IT IS INSUFFICIENT TO ATTACH YOUR OWN HEALTH RECORD, THIS FORM MUST BE COMPLETED IN FULL IN ORDER TO ATTEND KAMP KIWANIS
To be filled out by a Licensed Physician, Physician's Assistant or Nurse Practitioner representing the Licensed Physician 2009 MEDICAL EXAMINATION (DOCTOR TO COMPLETE):
Name___________________________________________Age______________Height____________ Weight____________ BP_______P_______ Vision R20/_________L20/_________Ears_________Throat_________Teeth_________Skin________ Respiratory_____________ Cardiovascular_____________ Musculoskeletal_____________ Neurological________________ Liver_________ Spleen_________ Genitalia_________ Hernia_________ U/A__________ Asthma___________________ The patient is under the care of a physician for the following condition(s): __________________________________________ Comments: ___________________________________________________________________________________________ INDIVIDUALIZED ORDERS: The following non-
ALLERGIES AND DIET
prescription medications are commonly stocked in the Kamp Health Center and are used on an as needed basis ALLERGIES: □ No Known Allergies
□ To foods (list):
Medical personnel: Cross out those items the
camper should not be given.
□ To Medications (list):
□ To the environment, (insect stings to include bees, hay fever, etc.
Cough Suppressants Decongestants (Sudafed & Sudafed PE) □ Other Allergies (list):
Pain reliever/fever reducer:Acetaminophen/Ibuprofen Scabies cream □ Has a medically prescribed meal plan or dietary restrictions (list):
Topical Antibiotics:Bacitracin/Neosporin/Bactroban Topical Antipruritics:Calagel/Hydrocortisone/Benadryl PRESCRIPTION MEDICATIONS AND TREATMENTS: Please complete with Patient’s current regimen for both scheduled and PRN medications to include peak flows,
nebulizer treatments, blood draws/lab work, diabetic testing, insulin administration, dressing changes, via GT etc.; please use the back sheet for additional medications as need.
Name of Medication
Date Started
Reason for taking it
When is it given
Amount or dose given
How is it given
□Lunch □Dinner □Bedtime □Other time □Lunch □Dinner □Bedtime □Other time LIMITATIONS ON ACTIVITY:
Swimming __________ Hiking ____________ Athletics ____________ Canoeing ____________ Other: ____________ Explain: ____________________________________________
_____________________________________________________________________________________________________________________________________________________
I certify that I have on this date examined the above named and that on the basis of my examination and medical history as furnished to me, I have found no reason which would make it medical y inadvisable for the kamper to participate in physically strenuous activities. Physician’s Signature _____________________________________________Date___________________________ Date of Examination__________________________

Please Print: Physician’s Name_______________________________________________________________________License # __________________________________________
Address______________________________________________________________________________________________________Phone # _______________________________
Mail completed form to: Kamp Kiwanis, 9020 Kiwanis Rd, Taberg, NY 13471 or Fax to: (315) 336-3845
2009 Kamp Kiwanis®
Health Exam by a Physician
Additional Medications
Name of Medication
Date Started
Reason for taking it
When is it given
Amount or dose given
How is it given
□Lunch □Dinner □Bedtime □Other time □Lunch □Dinner □Bedtime □Other time □Lunch □Dinner □Bedtime □Other time □Lunch □Dinner □Bedtime □Other time □Lunch □Dinner □Bedtime □Other time □Lunch □Dinner □Bedtime □Other time □Lunch □Dinner □Bedtime □Other time □Lunch □Dinner □Bedtime □Other time □Lunch □Dinner □Bedtime □Other time

Source: http://kiwanis-ny.org/kamp/pdf/09healthexam.pdf