Camp Wamp Physical Evaluation FormParent / Legal Guardian Contact Information: First Name Last Name Phone EmailTo Physicians and Their Staff:This person is a camper at Camp Wamp. The job includes physical activity such as lifting, hiking, and canoeing, and requires the individual to be outside in a variety of weather conditions. Our staff use the information provided on this form to guide their interface with the camper. If you question the person’s suitability for their participation, please talk with them and/or their parent/guardian about your concerns and develop a plan to address that concern. You can also speak to one of our camp professionals by calling 530.721.6369. Thank you!Camper Information: Name of Camper Date of Birth Date of ExaminationHeight Feet Inches Weight Blood Pressure (Systolic/Diastolic)The following medications are stocked in our Health Center and will be used to manage illness and/or injury.CHECK any that are contraindicated for this person. Contraindicated medicationsAcetaminophenAloeBismuth Chew TabsCalamine LotionChlorpheniramine maleateDiphenhydramineEpinephrineGuiafenesin DMHydrocortisone CreamIbuprofenKaopectateCough DropsIvy DryNixTolnaftateTopical Antibiotic CreamPseudoephedrineSilver Sulfadiazine List the chronic health problems of this personNoneAsthmaDiabetesAllergiesOther Other chronic health problems of this person not listed above. List the prescription medication(s) this person will take while at camp. List ALL patient allergies, known reactions and best course of treatment upon exposure. Note: We expect the person will have an EpiPen and know how to use it if anaphylaxis is a known reaction. Describe other treatments needed by this person while at camp to perform their job duties. Describe any significant physical findings regarding this person and/or describe any limitations that may impact the performance or participation. If you feel we have neglected to ask something you feelis needed to adequately address this person’s health,please add comments below.Doctor's SignatureBy signing this form, you are stating that, in your opinion, this person is both physically and emotionally ready to participate at our camp except as noted in your comments. To sign this form, click the "Submit" button and create a verified E-signature on the next page. Contact Information Download and Print this form for your Doctor to fill out.