Blank medical form by 4w269Or


                                    (This side to be filled in by parent before presentation to physician)

               CHILD'S LAST NAME                                          FIRST NAME                               BIRTHDATE           SEX

Home Address: ______________________________________________________ Phone: ________________________

Parent or Guardian: ____________________________________________________                                      Phone:

Place of Employment: Father (Guardian) _________________________________                                      Phone:
                            Mother (Guardian) _________________________________                               Phone:
In case of emergency, notify: ____________________________________________                                    Phone:

if Parent, Guardian are not available in an emergency, notify:
       1 -----------------------------------------------------------------------------------------------      Phone:
            ---------------------------------------------------------------------------------------------     Phone:

Important:          Has this camper been exposed to any communicable disease during the three weeks prior to camp attendance:
                    Yes Q No Q        (If yes, state type of exposure: ______________________________________________ )

HEALTH HISTORY: (Check box if child has had afflictions, give appropriate dates)
         Q Rheumatic Fever ____________________ D Hay Fever ____________________________
                Q       Seizures __________________________ -                            Q      Poison Ivy, etc.
                Q      Diabetes ___________________________                             3     Insect Stings —
                O      Asthma __________________ ------------                           Q      Penicillin ------
                LJ     Chicken Pox ________________________ Q                     Other Drugs
                                                                                        Q      Food ____

Other Past Illnesses _______________________________________________________
Operations or Serious Injuries (Dates)
Hospitalization (Dates) ___________
Chronic or Recurring Illness
Any specific activities to be encouraged?
Conditions that require activity to be restricted? .
Permission for all program activities unless otherwise noted by Dr.
Appliance worn (glasses, contacts, etc.) ____________________
Medication taken ______________________________________
Suggestion from Parent/Guardian.

                                   CONSENT FOR EMERGENCY MEDICAL TREATMENT
   / do hereby give authority to the Day Camp and Year Round Afterschool and Youth Center Program staff to obtain necessary
emergency medical treatment for my child with the understanding that the family will be notified as soon as possible.

Relationship ______________ Signature_____________________________ Date ____________ Tel.# _______________

Department of Health and Mental Hygiene                  _    The City of New York             _    Bureau of Food Safety and Community
OCR 7 (Rev. 1/06)
                                                   PHYSICAL EXAMINATION
                             (To be filled out by Physician - please note information on reverse side)

The purpose of this health record is to provide the staff with pertinent information which will help to serve the needs
of this child in Day Camps and Afterschool and Youth Center programs.
IMMUNIZATION HISTORY - This is arecord of dates of basic immunization and most recent booster doses.
DTaR DTP. DT. Td          Date _______      Date ________   Date _________                  Date __________           Date ________
Polio                  Date _________       Date ________   Date__________                  Date __________           Date________
MMR                    Date _________       Date ________   Date__________
Hemophilus Influenzae type b (Hib)        Date__________    Date _________                  Date __________          Date ________
Hepatitis B            Date _________ Date _____________    Date _________                  Date __________
Varicella              Date _________       Date ________
Conjugate (PCV)        Date _________ Date _____________ Date ____________                     Date ________          Date ________
Other ____________      Date _________      Other _______     Date ________                    Other _______          Date _____

MEDICAL EXAMINATION - To be filled out by licensed physician.
     Examination is acceptable when performed no more than 12 months prior to arrival at camp.
         Code: S = Satisfactory
                X = Not Satisfactory (Explain) 0
                = Not Examined
General Appearance ______________________________________________________________
Height            Weight            Rlnnri Pressure              Pn<stiirp X?       Throat                      - Tnn«il«i
Nose.             Teeth             Sninp
                                  Abdomen             Hernia        Feet        I. imps                              .Skin

Hgb. Test (Date) _________________ Urinalysis (Date) _______________
Eyes --------------Vision___________ w/Glasses ___________ Extremities_________________ Heart
Ears _________ Hearing __________
Neurological Findings ________________________
Describe Abnormal Findings and/or Handicapping Conditions

Allergy: (Please specify).

Recommendations and restrictions while in camp:

        Special Diet _________________________
        Special Medicine (dose, route of administration, when should it be administered).
        Is parent/guardian sending special medicine? _____________________________
        Activity Restrictions ________________________________________________
        Swimming __________________________________________ Diving

General Appraisal: ________________________________________________

1 have examined the person herein described, reviewed his/her health history and it is my opinion that he/she is physically able to
engage in Day Camp/Year Round Afterschool and Youth Center activities, except as noted above.

                                                                                            EXAMINING PHYSICIAN (SIGNATURE)

                                                                                              PHYSICIAN'S NAME (PLEASE PRINT)

Telephone _________________________            Address ______________________________________________________

Date of Examination __________________                   ___________________________________________________________
                                                                                                                                ZIP CODE
OCR 7 (Rev. 1/06)

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