A. OVERALL ASSESSMENT

Date of Physical Exam

MM

DD

YYYY

Clinical Diagnosis:

HIV

AIDS

None

Other

. 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

MM

DD

YYYY

Chest x-ray (If test positive or hx of disease)

MM

DD

YYYY

Date

MM

DD

YYYY

SIGNATURE OF LICENSED MEDICAL PERSONNEL

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Emergency Phone

(###)

###

####

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.

Yes

No