Camp Name
Camp Kanata
Camp Sea Gull
Camp Seafarer
Full Name
___________________________________________
THIS FORM TO BE COMPLETED BY A LICENSED PHYSICIAN
Last Name:
_______________________
First Name:
___________________
Date of Birth:
___ /___ /_____
THE OBJECTIVES OF THIS EXAMINATION ARE TO DETERMINE THAT THIS INDIVIDUAL:
1.
Is physically fit to engage in strenuous activities without harm to himself/herself or others.
2.
Has no significant infectious condition that could be transmitted to others
3.
Has no emotional or physical disorder that could not be cared for under the routine operations and programs of Camp.
Note: Some special conditions may be handled after individual discussions with Camp.
PHYSICAL
Weight
__________ Height __________ B.P.
_____ /_____
CODE
()
Normal
(X)
Abnormal (Explain)
Skin _________________________________
Nose _________________________________
Chest _________________________________
Extremities _________________________________
Eyes _________________________________
Throat _________________________________
Heart _________________________________
Spine _________________________________
Ears _________________________________
Teeth _________________________________
Abdomen _________________________________
Neurologic _________________________________
Menstrual History
(if applicable)
:
_____________________________________
Recommendations and Restrictions (diet, activity, etc.):
___________________________________________________________
_________________________________________________________________________________________________________
Known Allergies:
__________________________________________________________________________________________
Does this individual have chronic medical problems, emotional difficulties, eating disorders or behavioral issues
Yes
No
of which you are aware? If yes, please describe the condition:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Does this individual take routine medications or nutritional supplements? If yes, please list medications or
nutritional supplements. Note: A prescription must accompany any medications or supplements listed through camp's
contracted pharmacy.
_________________________________________________________________________________________________
Yes
No
MY SIGNATURE INDICATES I have reviewed the health history as well as examined this patient on _____ /_____ / _____ .
[DATE OF EXAM]
Date of Exam (within 12 mos of arrival to Camp)
PHYSICIAN’S SIGNATURE
___________________________________________________________ SIGNATURE DATE
_
_ / ____ / ____
YMCA
OVERNIGHT CAMP
2021 Health Form - Physician's Exam
