Health Care Recommendations by Licensed Medical Personnel I  examined  this  individual  on  ____________.  (ACA  accreditation  requirements  specify  exams  within  24  months  of  camp attendance. Individual camps may require annual exams. A new exam is not necessarily required for camp attendance.) BP  ____________ Weight  ____________ Height  ____________ In my opinion, the above applicant  o  is  o  is not  able to participate in an active camp program. The applicant is under the care of a physician for the following conditions Recommendations and Restrictions at Camp Treatment to be continued at camp Medications to be administered at camp (name, dosage, frequency) Any medically-prescribed meal plan or dietary restrictions Known allergies Description of any limitation or restriction on camp activities Additional information for health care staff at the camp Copyright 1983 by American Camping Association, Inc. Revised 1990, 1992, 1994, 1995, 1996, 1998, 1999, 2000. For camp use only Signature of Licensed Medical Personnel ____________________________________________________________ Printed   _____________________________________ Title   _______________________________________________ Address _________________________________________________________________________________________ Phone  ________________________________________________________________________ Date  _____________ Screening Record am Date screened   _____________________________________________________________   Time  _____________ pm Meds received   ___________________________________________________________________________________ Updates/additions to health history noted o Yes   o No   o None required Current health needs identified  ______________________________________________________________________ Observational notes  _______________________________________________________________________________ Screened by  ___________________________________________