Camp Broncho of North Texas – Provider Health Form
TO BE COMPLETED BY PROVIDER
An important note to Healthcare Providers:
This Medical Health History and Physical Examination form is a mandatory part of your patient’s asthma camp application. If applicable, please try to simplify
the medication regime that the child follows during camp. For example: if a medication can be given TID, with meals, instead of QID, (or BID instead of TID),
this would be helpful for the child and the medical personnel. Furthermore, inhalation therapy with a nebulizer can be time consuming for the child at camp;
please carefully review the child’s need for this form of therapy. ALLERGY SHOTS WILL NOT BE GIVEN AT CAMP.
Child’s Name_________________________ DOB: ___/___/___ Height (inches) ________ Weight (lbs)_______
BP ____/____
Immunizations UTD:
YES
NO
Date of Last Physical Exam ___/____/____
HISTORY (please circle yes or no)
1.
Any hospitalizations in the PAST 2 YEARS for asthma
2.
Has this child been:
3.
a.
in the ICU or intubated ever for asthma?
b.
On oral steroids within PAST YEAR ? Y
c.
Hospitalized for reasons other than asthma
Y
Y
N
N
# Admits _______ Most recent date ___/___/___
Month ______ Year______ # admits__________
N Most recent course ________________________
Y
N
# Admits _______
Does this child have any of the following problems?
Convulsive disorder……..
Hyperactivity…………….
Diabetes ………………….
Learning Disabilities …….
OCD ………………………
Y
Y
Y
Y
Y
N
N
N
N
N
Heart Disease ………….
Fainting …………………
Bedwetting ……………..
ADD ……………………..
Aggression………………
Y
Y
Y
Y
Y
N
N
N
N
N
Discipline Problems …………… Y
Sleepwalking …………………… Y
Constipation …………………… Y
OSA …………………………….. Y
Depression …………………….. Y
N
N
N
N
N
Explain any “yes” answers (include CPAP/BiPAP settings) _____________________________________________________
____________________________________________________________________________________________________
4. Does the Camp Healthcare Team need to be aware of any of the following:
a. Known medical problems, beside asthma ? …………………………………..
b. Known behavioral or psychological issues? …………………………………..
c. Foods that must be completely eliminated from this patient’s camp diet ……
d. Other allergy or sensitivity problems ? …………………………………………
e. Specific medication issues … ……………………………………………………
Y
N
Y
N
Y
N
Y
N
Y
N
Please explain any “YES” answers ( Please be specific) _______________________________________________________
____________________________________________________________________________________________________
5.
How would you rate the currently level of control of child’s asthma ? (circle one)
Well Controlled
Not Well Controlled
Very Poorly Controlled
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Camp Broncho of North Texas Camper Application
MEDICATIONS
Drug Name
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Strength
Dosage
Frequency
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
See Attached Form
Is this child allergic to any:
Medications: __________________________
__________________________
__________________________
__________________________
Reaction: ________________
________________
________________
________________
N/A
Foods:
Reaction: ________________
________________
________________
________________
N/A
Reaction: ________________
________________
________________
N/A
__________________________
__________________________
__________________________
__________________________
Animals or Insects: _____________________
_____________________
_____________________
HEALTHCARE PROVIDER’S AUTHORIZATION
I have examined the above camp applicant. My signature below indicates that I believe this patient is able to participate
in an active camp program designed for children with asthma.
____________________________
Healthcare Provider Signature
_____________
Date
____________________________
Clinic or Office
(___)___________________
Telephone
_______________________________
__________________________
Address
______________________________
Printed Name of Healthcare Provider
__________________
____________
City
***Please return to 682-885-6255. Thank you.
11/30/12
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Camp Broncho of North Texas Camper Application