LISTA DE CONTROL PARA LA SOLICITUD A LA SESIÓN DE ...

Camper Medical Provider Form
CMPF
Page 1 of 4
To Be Completed By Health Care Provider (Physician/Nurse Practitioner /Physicians Assistant) Prior to Submission Of This Application
Please Be As Detailed As Possible And Answer All Questions.
If child routinely has lab work, please attach most recent lab results.
Today's Date
Camper Name
Date of Birth
Primary Diagnosis
With any subclassification
Date of Diagnosis
State of Current Condition Stable Flare Medicated Remission Remission Other
Current Problem List:
Asthma Mild intermittent Moderate Persistent Severe Persistent
Other
ADD/ADHD
Renal Insufficiency
Asplenia
PTLD
Diabetes Type I
Severe Visual Problems
TPN-Dependent
Acute Cellular Rejection
Diabetes Type II
Heart Problems *
IV or Subcutaneous Meds
Chronic Rejection
Hypertension
Lung Problems *
Hepatitis B
Autoimmune Hepatitis
Migraine Headaches
Fracture Risk *
Hepatitis C
HAT/PVT/Biliary Complications
Sleep Apnea
Bleeding Risk *
CMV Disease
Bedwetting
Recurrent Group A Strep
HIV
Stool incontinence
Recurrent Skin Infection
Tb
Obesity
Seizures
Type
Duration
Date of last Seizure
* Explanation
Significant past medical history/other medical conditions:
Is the child developmentally appropriate for his/her age Yes No
If no, at what (approximate) age does child function
List any communication problems, pertinent psychosocial information, or behavioral
problems that would affect the child's participation in a group:
Major Surgeries & Dates (e.g. transplants)
Infection Control
Has the child ever had chicken pox or shingles Yes No Year of infection
Live vaccines deferred Yes No
Are you aware of any positive history for:
HA-MRSA
VRE
Yes
Yes
No
No
If yes, date cleared
If yes, date cleared
We cannot accept these
campers unless infection has
been cleared