Youth Camp Pre-Participation Physical Assessment
Camper Information
Full Name
Date of Birth
Sex
Female
Male
Other
Age
Parent/Guardian Name
Contact Number
Address
Medical History
Allergies
Asthma
Diabetes
Seizures
Heart Condition
Other (please specify below)
If any, please describe further
Current Medications
List medications (with dosages and schedule)
Immunizations
Up-to-date?
Yes
No
If not, please specify
Physical Examination
Height
Weight
Blood Pressure
Pulse
Vision
Hearing
Remarks/Abnormal Findings
Physician Clearance & Signature
Physician Name
Date of Exam
Physician Signature