Physical Examination Form - Hagalil Usy printable pdf download

INSTRUCTIONS

This Health Form may be separated from Camp Application form.

Return To: Kadima Encampment or USY Encampment

PHYSICAL EXAMINATION FORM

1090 King Georges Post Rd., Suite 304 Edison, NJ 08837

To be filled out by licensed physician.

NAME OF CHILD: ___________________________________ DATE OF EXAMINATION:____________

Please record the date (month and year) of basic immunization and most recent booster doses:

Vaccines

Year of Basic Immunization

Year of Last Booster

Diphtheria

Pertussis (Whooping Cough)

Tetanus

Diphtheria

Tetanus

Oral Polio (Sabin)* TOPV

Injectable Polio (Salk)

Measles

(hard measles, red measles,

Rubeola)

Mumps

Rubella

(German measles, 3-day measles)

Other

Tuberculin test given ____

(most recent)

Health Examination by Licensed Physician

Code:  -- Satisfactory

x – Not Satisfactory (explain)

Hgt. ________ B.P. _______

Urinalysis test done ___________ Wt. ______________ Hgb. Test

done _________

Eyes _______ Extremities __________ Glasses _________

Posture (Spine) _________ Ears

____________

Skin _______

Nose ______

Allergies (please specify) ___________________________________

Teeth ______ Heart ______ Menstrual history ___________ Lungs _________ Abdomen

Throat __________ Genitalia __________

Hernia ______________ General appraisal

I have examined the above camp applicant on (date)

____________________________________________________

In my opinion, the above condition does _____/does not ______ preclude his/her participation in an

active camp program.

The applicant is under the care of a physician for the following condition(s):

____________________________________________________________________________________

Current treatment (include current medication):

____________________________________________________________________________________

Is child recovering from addiction, eating disorders or psychological issues?

____________________________________________________________________________________

Explanation of any reported loss of consciousness, convulsion, or concussion

____________________________________________________________________________________

Does applicant have epilepsy? Yes ____ No ____Does applicant have diabetes? Yes ___ No ____

Recommendations and Restrictions While at Camp (diet, medicine, treatment, etc.)

____________________________________________________________________________________

Additional Health Information _________________________________________________________________

X Licensed Physician’s Signature ________________________________________

Please print physician’s full name:

Full Address _______________________________________________________ Phone

*Initial if completed by nurse or physician’s assistant.

Physical Examination Form - Hagalil Usy

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