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