CAMPER MEDICAL EXAMINATION

THIS PAGE MUST BE COMPLETED BY A LICENSED MEDICAL PERSONNEL
A. OVERALL ASSESSMENT

Date of Physical Exam
A. OVERALL ASSESSMENT

Date of Physical Exam
Clinical Diagnosis:
. TUBERCULOSIS (TB) SKIN TESTING OR INTERFERON GAMMA RELEASE ASSAY (IGRA)

The American Academy of Pediatrics recommends annual TB skin tests for all HIV-infected children; it is also recommended for children who reside with HIV-infected adults. TB testing information is required for the child’s participation. A TB skin test result must be documented within the past 12 months. This is an absolute requirement!

Most recent TB Skin Test OR IGRA
. TUBERCULOSIS (TB) SKIN TESTING OR INTERFERON GAMMA RELEASE ASSAY (IGRA)

The American Academy of Pediatrics recommends annual TB skin tests for all HIV-infected children; it is also recommended for children who reside with HIV-infected adults. TB testing information is required for the child’s participation. A TB skin test result must be documented within the past 12 months. This is an absolute requirement!

Most recent TB Skin Test OR IGRA
Chest x-ray (If test positive or hx of disease)
Chest x-ray (If test positive or hx of disease)
Date
Date
SIGNATURE OF LICENSED MEDICAL PERSONNEL
SIGNATURE OF LICENSED MEDICAL PERSONNEL
Address
Address
Phone
Phone
Emergency Phone
Emergency Phone
MEDICATIONS
Please list ALL medications (including over-the-counter and/or non-prescription drugs) taken routinely. Bring enough medication to last the entire week of camp. Keep all medications in their original packaging/ bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration.

This person takes NO medication on a routine basis.