Microsoft word - medical recommendation revised 10-9-07.doc
To Parent(s)/Guardian(s):Complete this section and give this form(FORM 2) and a copy of your completedCAMPER HEALTH HISTORY FORM (FORM 1) to your child’s health-care provider for review.
Developed and reviewed by: American Camp Association,
Dates wil attend camp: from ______________to_____________
American Academy of Pediatrics Council on School Health, &
Camper Name: _____________________________________________________________
" Male !" Female !!!Birth Date ____________ Age on arrival at camp ________
Mail this form to the address below by _______ (date)
Camper home address: ________________________________________________________
Custodial parent(s)/guardian(s) phone: (_______)______________ (_______)____________
Parent(s)/guardian(s) stop here. Rest of form to be completed by medical personnel.
The following non-prescription medications are
Medical Personnel:Please review the CAMPER HEALTH HISTORY FORM (FORM 1) and complete all
commonly stocked in camp Health Centers and are
remaining sections of this form (FORM 2). Attach additional information if needed.
used on an as needed basis to manage illness and
injury. Medical personnel:Cross out those items the Physical exam done today: " Yes " No (If “No,” date of last physical: ___________) camper should not be given. ACA accreditation standards specify physical exam within last 24 months.
Weight: _______ lbs Height: _____ft_____in Blood Pressure_______/_______
Pseudoephedrine (Sudafed) Chlorpheneramine maleate
Allergies: " No Known Allergies
" To foods (list):
" To medications: (list):
Lice shampoo or scabies cream (Nix or Elimite)
" To the environment (insectstings, hay fever, etc.–list):
" Other al ergies: (list): Describe previous reactions: Diet, Nutrition: " Eats a regular diet. " Has a medical y prescribed meal plan or dietary restrictions:(describe below) The camper is undergoing treatment at this time for the following conditions: (describe below) " None. Medication: " No daily medications. " Wil take the fol owing prescribed medication(s) while at camp: (name, dose, frequency—describe below) Other treatments/therapies to be continued at camp: (describe below) " None needed. 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 FORM (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: _________
Copyright 2008 by American Camping Association, Inc.
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PREFERRED DRUG LIST CONVERSION TABLE January 2002 BOLD TYPEFACE indicates product is available at the preferred generic copayment tier. CAPS indicates product is available at the preferred brand copayment tier. NON-PREFERRED DRUG PREFERRED ALTERNATIVE Ranitidine 300mg Cimetidine 800mg Famotidine 40mg Cardiovascular Agents – Calcium Channel Blockers Diltiaz