The above patient was examined on___________________.
The patient's health history and immunization records were reviewed.

Weight:____________ Height:____________ BP:____________

Vision: Left____________ Right____________ Color____________ Postural Screen____________

Allergies:______________________________________________________________________
______________________________________________________________________________

Chronic Medical Problems:________________________________________________________
_______________________________________________________________________________

Medications/Treatments:__________________________________________________________
_______________________________________________________________________________

Dietary Restrictions:______________________________________________________________
_______________________________________________________________________________

I SEE NO REASON(S) TO RESTRICT FULL PARTICIPATION IN CAMP ACTIVITIES.

Physician's Name (Printed): _________________________________ Phone #:__________________

Physician's Signature: ______________________________________ Date:_____________________

PARENTS: I CERTIFY THAT MY CHILD HAS NOT INCURRED ANY SIGNIFICANT HEALTH
PROBLEM(S) SINCE THE DATE OF THE ABOVE PHYSICAL EXAM.

Parent's Signature: _________________________________________ Date:_____________________

DPT/DTaP/DT