Mount Wachusett Community College
Campers Name:
Date of Birth:
Parent/Guardian:
Relationship:
Address:
Phone Number:
Emergency day-time number:
Campers Medical Insurance:
Name of policy holder:
IMMUNIZATIONS
DTP
(Diphtheria
Tetanus
Pertussis)
Td
Tetanus Diphtheria
Adult Type
Date
Summer Camp Health Record
2017
Campers Address:
Sex:
Parent/Guardian:
Relationship
Address:
Phone Number:
Emergency day-time number:
Policy Number:
IMMUNIZATIONS
Polio
Oral Trivalent
(TOPV)
at least 4 doses
Date
IMMUNIZATIONS
MMR (combined)
TETANUS TOXOID
OTHER
Immunizations
MEASLES
MUMPS
RUBELLA
Date
SPECIAL TEST
TUBERCULIN TEST
Results
Date
LEAD TEST
MEDICAL HISTORY (give dates)
Accidents
Allergy
Chicken Pox
Congenital Anomaly
Convulsions
Diabetes
Ear Infections
Encephalitis
Rubella
Heart Disease
Hernia
Kidney Disease
Measles
Meningitis
Mumps
Operations
Poliomyelitis
Rheumatic Fever
Scarlet Fever
Strep Throat
Tonsillitis
Tuberculosis
Whooping Cough
Other
PERTINENT FAMILY MEDICAL HISTORY
SUMMARY OF SIGNIFICANT TREATMENT PROGRAMS INCLUDING CURRENT MEDICATIONS AND ALLERGIES, AND
SUGGESTIONS FOR PROGRAM ADJUSTMENT IF INDICATED.
Mount Wachusett Community College
Summer Camp Health Record
2017
PRIVATE PHYSICIAN’S EXAMINATION (within past 24 months)
In order to ensure a quality standard of complete examination for each camper, please record you findings after each item.
(O) normal
Comment
DATE:
(X) abnormal
Treatment
Age: __________
BP: _______/_______
Pulse: __________ Hgt.: ___________ Wgt.: ______
Physical Development: _____________________________________________________________
Nutritional Status: ________________________________________________________________
Skin: ____________
Eyes: ____________ Sclera: ___________
Pupil: __________
Light & distance: ____
r: ______________ l: ______________
Glasses: ___________
Ears: ____________ Canals: r: __________
l: ______________
Drums: r: __________
l: ______________
Nose: ___________ Septum: ___________
Turbinate: ______
Mouth: __________ Lips: ______________
Tongue: ________ Pharynx: ________
Teeth: ___________ Gingiva: ___________
Neck: ___________ Mobility: __________
Lymph nodes: ___ Thyroid: ________
Throat: __________ Shape: ____________
Symmetry: ______
Lungs: ___________
Heart: ___________ Rate: _____________
Rhythm: ________ Murmur: _______
Abdomen: _______ Liver: _____________
Spleen: _________
Hernias: ___________
Ano-Genital: ______ Anus: _____________
Penis: __________ Labia: __________
Testicles: r: ________
l: ____________
Tanner stage: ________
Spine: ___________
Lower Extremities: ________________
Range of motion: _______________
Development:__________
Strength: __________
Upper Extremities: ________________
Range of motion: _______________
Development:__________
Strength: __________
Cranial Nerve: ___________________
I-XII: __________________
Gait: ___________
Coordination: _________________
Having examined the above camper enrollee, I find him/her medically and physically able to participate in the Mount
Wachusett Community College Summer Camp/Sport program.
Physicians Name (printed)
Physicians Signature
Date: ___________________________________
Physicians Address: __________________________________
______________________________________________