CAMP PINEHURST
 MEDICAL HISTORY AND  
 PHYSICAL EXAM FORM
                      Camp Pinehurst       
                        23 Curtis Road
                   Raymond, Maine 04071

NAME_________________________________________________Parent / Guardian_____________________________________
HOME ADDRESS_______________________________________________BIRTHDATE___________Social Security#____-___-____
WORK ADDRESS__________________________________________________________________________________________
TELEPHONE  #    HOME_______________________WORK_____________________CELL /PAGER______________________

EMERGENCY CONTACTS

NAME___________________________________RELATIONSHIP_______________________ TEL.#_______________________
NAME___________________________________RELATIONSHIP________________________TEL.#_______________________

IMMUNIZATION RECORD / ALLERGIES

Last DT Booster__________     MMR___________                     Penicillin______     Other drugs__________
Polio Series completed _________ ChickenPox_______            Bee stings_______    ( will bring own Epipen)      Asthma__________                                                                         
                                                                                                       Ivy / Oak / Sumac       Foods_________________________
  PHYSICIAN STATEMENT: The child is capable of participating in all camp activities unless noted specifically on reverse side.
Written orders for ALL prescription drugs being administered while child attends camp MUST accompany this form. Use additional page if needed.
1.___________________________________________________________________________________________________________
2.___________________________________________________________________________________________________________
3.___________________________________________________________________________________________________________
PHYSICIAN'S  SIGNATURE___________________________________Printed Name____________________DATE____________

PARENTAL STATEMENT   When the camp secures medical attention for my child, I grant permission to Doctors to utilize medical tests and x-rays. In an emergency and I cannot be reached, I authorize doctors to immediately begin proper treatment including injections, anaesthesia, and surgery.

SIGNATURE_________________________________________________________Parent / Guardian    DATE_____________-  WITNESS_____________________________________________________

THE CAMP MUST BE NOTIFIED IF THIS CHILD HAS OR IS EXPOSED TO ANY COMMUNICABLE DISEASE WITHIN THREE WEEKS PRIOR TO ENTERING CAMP!


PHYSICIANS  EXAM

HEIGHT ____________          WEIGHT  ____________                       BLOOD PRESSURE _________________

URINALYSIS ________________                    HCT or HGB TEST_______________              TINE____________

ABNORMAL FINDINGS  __________________________________________________________________________
_______________________________________________________________________________________________

HEALTH BACKGROUND

Circle any that pertain to this child:

Bedwetting                          Chronic ear infections                         Frequent strep throat                             Diabetes

Blood disorders                         Heart disorders                     Pollen, dust, mold allergies :             injections required?

Eyeglasses               Corrective  shoes or orthotics                Hearing aids                       Orthodontic appliances

Parent or Physician comments on the above_______________________________________________________________
___________________________________________________________________________________________________

CAMPER RESTRICTIONS

Physical____________________________________________________________________________________________
Dietary_____________________________________________________________________________________________
Medical treatments in progress__________________________________________________________________________

MEDICAL CONTACTS

Pediatrician or family doctor______________________________________________________
Address_______________________________________________________________________TEL#__________________

Dentist________________________________________________________________________TEL#__________________

Orthodontist____________________________________________________________________TEL#__________________

Optometrist / Opthamologist_______________________________________________________TEL#___________________