LICENSED HEALTH CARE PROVIDER FORM
To be completed by Physician- Please complete the form below and attach additional information
Student Name:
First
Middle
Birth Date:
Gender:
Last
□ Male
□ Female
Phone:
Month/Day/Year
Address
City
DIET & NUTRITION □ This student eats a regular diet
State
Zip/Postal Code
Country
□ This student has a medically prescribed meal plan or dietary restrictions (describe below):
ALLERGIES
□ No known allergies □ To Food (list):
□ To medications (list):
□ To the environment (insect stings, hay fever, etc-list):
□ Other allergies: (list):
Describe previous reactions:
TREATMENT □ None □ The student is undergoing treatment at this time for the following conditions (describe below):
MEDICATION □ No daily medication(s)
□ This student will take the following prescribed medication(s) while on the program (describe below name(s), dose(s) frequency):
OTC MEDICATION I authorize the on-site nurse to provide over the counter medication to students as needed in non-life threatening
circumstances.
Yes□
No□
Please list any exceptions if applicable
.
PHYSICAL EXAMINATION
I have examined the above participant. Date of Exam*:
Weight
Height
Which of the following has participant had?
(Month/Day/Year) (*required exam date must be in the past 12 months)
Blood Pressure
□ Measles □ German measles □ Mumps □ Hepatitis A □ Hepatitis B □ Hepatitis C
RESTRICTIONS □ I have reviewed the program and activities of the program and feel the student can participate without restrictions
□ I have reviewed the program and activities of the program and feel the student can participate with the following restrictions or adaptations.
Please describe:
IMMUNIZATION HISTORY Provide the month and year for each immunization. Starred (*) immunizations must be current. Copies of immunization
forms from health-care providers or state or local governments are acceptable; please attach to this form.
Last Booster
Completed
Last Booster
Completed
Immunizations
Immunizations
Diphtheria, tetanus, pertussis*
Haemophilus influenzae type B
(DTap) or (TdaP)
Pneumococcal (PCV)
Tetanus booster* (dT) or (TdaP)
Hepatitis B
Hepatitis A
Mumps, measles, rubella (MMR) *
Polio* (IPV)
Varicella (chicken pox)
□ Had Chicken Pox
Meningococcal Meningitis (MCV4)
Tuberculosis (TB) Test: date
Date
result □ Negative □ Positive
Please provide any additional information regarding the participant’s behavior and physical, emotional, or mental health about which the pre-college program
should be made aware (Continue on an additional page if necessary):
I have reviewed the Student’s Health History, and have discussed to the pre-college program with the student’s parent(s)/guardian(s).
It is my opinion that the student is physically and emotionally fit to participate in an active pre-college enrichment program (except as noted).
Name & Title
Office Address
Signature
Date
Phone
*This form contains information from the American Camping Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses
(Parents: Please upload completed form in the Document Upload section of your Student Medical and Health History Form)