Physician’s Evaluation

PHYSICIAN’S EVALUATION TO BE COMPLETED BY A PHYSICIAN

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Grade in Sept. 2019

Student’s Last Name

Student’s First Name

Upload completed form to student’s CampDoc health profile or mail/fax directly to: EXPLO 932 Washington Street Norwood, MA 02062

Under the regulatory authority of Massachusetts General Law and the Connecticut Department of Public Health, any student attending a summer program in Massachusetts or Connecticut is required to have a completed medical form on file with the summer program. EXPLO will not allow the student to attend the program without the completed physician’s evaluation and a completed immunization history. Physical exams must have been conducted on or after August 3, 2017. *** Please note: a physician may substitute his or her own form providing it covers the same information listed below. The physician’s form must include the student’s name and be signed and dated by the physician. ***

Fax: 781.787.2742 RETURN NO LATER THAN APRIL 1

Patient information Date of Birth

Height

Weight

Pulse

Blood Pressure

Immunization

Dose 1 MM/YYYY

Dose 2 MM/YYYY

Dose 3 MM/YYYY

Dose 4 MM/YYYY

Dose 5 MM/YYYY

Most Recent Dose

Diptheria, tetanus, pertussis (DTaP) At least 4 doses are required Tetanus booster (Td) or (TdaP) Most recent dose must be given after August 3, 2009

Mumps, measles, rubella (MMR) 2 doses are required

Polio

At least 3 doses are required, with the last dose

given on or after the 4th birthday

Hepatitis B

3 doses are required Meningococcal meningitis Dose must be given after August 3, 2014

Varicella (chicken pox)

2 doses are required OR verification of disease (enter date below:)

Please note: you may have your doctor provide titer (serology) results showing immunity and upload the lab results to your CampDoc health profile.

STUDENT HEALTH HISTORY Allergies or Reactions to Medications? ☐ NO ☐ YES (Specify)

Are there conditions or impairments that may affect this student’s full participation in activities at the Program? ☐ NO ☐ YES (Specify)

Life Threatening? ☐ NO ☐ YES Life Threatening? ☐ NO ☐ YES Life Threatening? ☐ NO ☐ YES Clinical Evaluation (including current or chronic medical conditions)

Does this student take any kind of medication (including inhalers or epinephrine)? ☐ NO ☐ YES

PHYSICIAN’S INFORMATION Name

Address

Physician’s Signature

Phone Number

Date

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