LHVP Summer Camp - Physical Examination Form

Child's name (last/first):

______________________________________	was examined and found in good health and
	able to participate in all athletic programs.

Positive Physical Findings:

Recommendations and/or exceptions:

Date of birth:

Height:

Weight:

Blood pressure:

Pulse:

PPD:

Urinalysis

HGB:

Scoliosis:

Hearing:

Vision Screen:

Immunizations:

DtaP:

__________

Td. Booster:

__________

IVP/OPV:

__________

MMR:

__________

Hep B:

__________

HIB:

__________

VARIVAX:

__________

List any pertinent history concerning child's health (use reverse side if necessary)

Allergies:

Medication:

Surgical:

Date of exam:

(Please print)

Physican's signature:

_____________________

Physician's name:

Physician's address:

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