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Camp Checkup

 

Child's name ______________________________________________ 

I performed a complete physical examination on this patient 
on ________________.  

Medical problems: 

___________________________________________________________

___________________________________________________________ 

___________________________________________________________ 


___ This child is not contagious for any infectious diseases.  


This child's allergies are: _______________________________  

___________________________________________________________  


This child's medications are: ______________________________ 

____________________________________________________________ 


___ This patient can participate in all sports and 
    activities  OR

___ This patient should have limited activity as follows: 

____________________________________________________________

____________________________________________________________ 


___ This patient can eat a regular diet  OR 

___ This patient has the following dietary restrictions: 

____________________________________________________________

____________________________________________________________


Physician's name ___________________________________________

Physician's signature _____________________ Date ___________ 

Physician's phone number ____________________________  
Published by McKesson Provider Technologies.
Last modified: 1997-04-01
Last reviewed: 2004-09-28
This content is reviewed periodically and is subject to change as new health information becomes available. The information is intended to inform and educate and is not a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional.
Copyright 2006 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved.
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