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 ____________________________

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