Medical Physical Information

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(To be completed by a licensed medical professional qualified to conduct physical exams.)

Individual's Name *

Date of Birth: *

YYYY

Height: *

Weight: *

Blood Pressure *

Vision: *

Vision 20/40 or better in Left Eye

Vision 20/40 or better in Right Eye

N/A

Required

Hearing: *

Left Ear Responds

Left Ear No Response

Right Ear Responds

Right Ear No Response

Required

Ears: *

Left Ear Canal Clear

Left Ear Canal Cerumen

Right Ear Canal Clear

Right Ear Canal Cerumen

Left Tympanic Membrane Clear

Left Tympanic Membrane Perforation

Left Tympanic Membrane Infection

Right Tympanic Membrane Clear

Right Tympanic Membrane Perforation

Right Tympanic Membrane Infection

Required

Oral Hygiene *

Good

Fair

Poor

Thyroid Enlargement: *

Yes

Lymph Node Enlargement: *

Yes

Heart Murmur: *

Yes

Heart Rhythm: *

Regular

Irregular

Lungs: *

Clear

Not Clear

Abdominal Tenderness: *

Yes

Kidney Tenderness: *

Yes

Abnormal Gait: *

Yes

Spasticity: *

Yes

Tremor: *

Yes

Reflexes: *

Normal

Diminished

Hyperreflexia

Right Upper Extremity Reflex

Left Upper Extremity Reflex

Right Lower Extremity Reflex

Left Lower Extremity Reflex

Mobility: *

Full

Not Full

Neck and Upper Back Mobility

Upper Extremity Mobility

Lower Extremity Mobility

Strength: *

Full

Not Full

Upper Extremity Strength

Lower Extremity Strength

Free of Nits/Lice: *

Yes

Describe any Abnormal Findings: *

Any other pertinent information concerning this individual’s health that we should be aware of? *

Participation: *

This individual can participate in all activities at Camp Grassick with NO RESTRICTIONS.

This individual can participate in all activities at Camp Grassick WITH RESTRICTIONS.

Please explain any restrictions: *

I have examined this individual and find him/her free of communicable diseases, free of nits and lice and fit to attend Elks Camp Grassick if he/she is accepted. I understand that entering my name below is electronically signing this document. (Please type physician's name, clinic, phone number, and address.) *

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