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C:\wpdocs\2011\2011 staff forms\2011 medical examination form.wpd

2011 STAFF MEDICAL EXAM/PHYSICIAN FORM
Prior to May 15th, please return to CAMP KAMAJI FOR GIRLS, 7436 Byron Place, St. Louis, MO 63105
After May 15th, please return to CAMP KAMAJI FOR GIRLS, 32054 Wolf Lake Road, Cass Lake, MN 56633
To Physicians: This person has enrolled in a summer residential program at Camp Kamaji for Girls. This program includes
physical activity (i.e., swimming, canoeing, tennis, horseback riding, climbing wall!!) and takes place in the Minnesota North
Woods. Our healthcare staff will use your information to help meet the health needs of the person described.

NAME: BIRTHDATE AGE
HEIGHT: FT. IN.
WEIGHT: LB.
BP: RESTING HEART RATE:
“ This person’s immunization record is up-to-date. Yes “ No “ PLEASE ATTACH A COPY OF RECORD
“ This person is under the care of a physician for the following reason(s):
“ Describe any treatment(s) to be continued at Camp Kamaji for this person: “ This person takes medication. Yes “ No “ PLEASE LIST ALL MEDICATIONS (PRESCRIPTION AND OTC) ON OVERSIDE
ALONG WITH DOSAGE AND REASONS FOR TAKING. KKK KK
“ This person will suspend specific medication while at camp. Yes “ No “ PLEASE LIST MEDICATION ON OVERSIDE AND
REASONS FOR SUSPENSIONKKKKKKKKK
Should exposure occur, how should the allergic reaction be treated? If this is an anaphylactic response, will this person be bringingan epinephrine device?: “ Describe significant physical findings regarding this person and/or describe limitations which may impact the person’s participation Mental, Emotional and Social Health: Please check any that apply and explain further on overside.
“ This person has been diagnosed with Attention Deficit Disorder (ADD) Or ADHD.
“ This person has a psychiatric diagnosis such as depression, OCD, panic/anxiety disorder.
“ This person has an emotional health concern (specify )“ During the past academic year, this person has seen or is currently seeing a professional to address mental/emotional concerns.
“ This person has had a significant life event that continues to affect her/his life at camp.
Over-The-Counter Medications (OTCs): These medications, stocked in Kamaji’s Health Center, are used to manage illness or
injury concerns and are used on as as needed basis. PLEASE CROSS OUT those which are CONTRAINDICATED for this person:
— please turn over —
CAMPER/CIT NAME:
MEDICATIONS this person usually takes but which are being SUSPENDED during the time she is at camp and REASONS FOR
SUSPENSION:
Please list all MEDICATIONS, both prescription and over-the-counter, TO BE ADMINISTERED at Kamaji (name, dosage, frequency)
and reason for taking.
Name of Medication
Reasons for Taking It
Doses Given and When
“ Breakfast Dose: “ Lunch Dose: “ Dinner Dose: “ Bedtime Dose: “ Other: “ Breakfast Dose: “ Lunch Dose: “ Dinner Dose: “ Bedtime Dose: “ Other: “ Breakfast Dose: “ Lunch Dose: “ Dinner Dose: “ Bedtime Dose: “ Other: “ Breakfast Dose: “ Lunch Dose: “ Dinner Dose: “ Bedtime Dose: “ Other: “ We may have neglected to ask something you feel is needed to adequately address the health needs of this person. In
that case, please add your comments below. Thank you for helping provide a successful camp experience for this person.

I have examined the person herein described and have discussed the camp program with the camper’s parent(s)/
guardian(s). It is my opinion that the camper is physically and emotionally fit to participate in an active camp program
(except as noted on overside.)
Signature of Examining Physician/Nurse Practitioner:
Date of Most Recent Medical Examination:
Print or Stamp Physician’s Name:
Address:
Phone and Pager (w/Area Code):

Source: https://www.kamaji.com/wp-content/uploads/2011MedicalExaminationFormforStaff.pdf

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