Microsoft word - camperhealthcarerec.doc
CAMPER HEALTHCARE RECOMMENDATIONS BY LICENSED MEDICAL PERSONNEL FORM 2
To Parents(s)/Guardian(s): Complete this section and give this form (FORM 2) and
a copy of your completed
CAMPER HEALTH HISTORY FORM (FORM 1) to your child’s health-care provider for review.
Camp Glen Brook
Dates will attend camp: _____/_____/_____ to _____/_____/_____
35 Glen Brook Rd.
Month Day Year
Month Day Year
Marlborough, NH 03455
Camper Name: _______________________________________________________________________
F Birth Date: _____/_____/_____ Age on arrival at camp _________
Custodial parent(s)/guardian(s) telephone: (______) _______________________________
PARENT(S)/GUARDIAN(S) STOP HERE. REST OF FORM TO BE COMPLETED BY MEDICAL PERSONNEL.
Physical exam done today
: □ Yes □ No (If no, date of last physical _____/_____/_____)
ACA accreditation standards specify physical exam within last 24 months.
Center and will be used on an as needed basis to manage illness
Weight _______ lbs Height ________ft _______ in Blood Pressure ________/________
No known allergies
those items the
The environment (insect stings, hay fever, etc.) (list)
Antibiotic cream, topical Antihistamine/allergy medicine
Describe previous reactions:
Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol)
Calamine lotion Chlorpheniramine maleate
Dextromethorphan cough syrup (Robitussin DM)
This camper eats a regular diet Has a medically prescribed meal plan or dietary
restrictions: (describe below)
Guaifenesin cough syrup (Robitussin) Hydrocortisone Cream
This camper is undergoing treatment at this time for the following conditions: (describe below).
Ibuprophen (Advil, Motrin) Ivy Dry Laxatives for constipation (Ex-Lax) Lice shampoo or cream (Nix or Elimite)
No daily medications Will take the following prescribed daily medication(s) while at camp.
(name, dose, frequency – describe below)
(Sudafed PE) Pseudoephedrine decongestant
Other treatments/therapies to be continued at camp: (describe below)
Do you feel that the camper will require limitations or restrictions to activity while at camp?
□ No □ Yes
If you answered “Yes” to the question above, what do you recommend? (describe below – attach additional information if needed)
“I have reviewed the CAMPER HEALTH HISTORY FORMS (FORM 1), and have discussed the camp program with the camper’s parent(s)/guardian(s). It is my opinion that the camper is physically and emotionally fit to participate in an active camp program (except as noted above).
Name of licensed provider (please print): ________________________________________ Signature ______________________________________ Title ___________________
Office Address ___________________________________________________________________________________________________ Street Address City State Zip Code
Telephone (______) _______________________________ Date _____/_____/________
Copyright 2008 by American Camping Association, Inc. Rev. 2/2007 LEE/EAW
Searching for shoes that fits the aching feet - a Marketer’s solution Abstract The world economy and the marketplace today are deeply stuck in the mud of a far-reaching recession. The crisis is still unfolding. There remains great uncertainty as to the depth and severity of the crisis as well as its impact on the real sectors (so called main streets). During this tough
European Journal of Obstetrics & Gynecology and Reproductive Biology, 47 (1992) 121-127 992, Accepted for publication 13 August 1992. The reliability, acceptability and applications of basal body temperature (BBT) records in the diagnosis and treatment of infertility. Antonio R. Martinez, Marcel H.A van Hooff, Erik Schoute, Maartje van der Meer, Frank J.M. Broekmans and Peter G.A. Ho