Medical Physical Exam Form for Elks Camp Grassick
Date of Exam
*
-
Month
-
Day
Year
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Name of Physician
*
First Name
Last Name
Name of Examinee
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
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Examination
Sex
Female
Male
Other
Vitals
Vision
R
L
Hearing
R
L
Medical Examination
Normal/ Abnormal
Short Notes
Appearance
Normal
Abnormal
Not Examined
Eyes
Normal
Abnormal
Not Examined
Ears
Normal
Abnormal
Not Examined
Nose/throat
Normal
Abnormal
Not Examined
Lymph nodes
Normal
Abnormal
Not Examined
Thyroid
Normal
Abnormal
Not Examined
Heart
Normal
Abnormal
Not Examined
Murmurs
Normal
Abnormal
Not Examined
Pulses/Rhythms
Normal
Abnormal
Not Examined
Lungs
Normal
Abnormal
Not Examined
Abdomen
Normal
Abnormal
Not Examined
Skin
Normal
Abnormal
Not Examined
Neurologic
Normal
Abnormal
Not Examined
Musculoskeletal Examination
Normal/ Abnormal
Short Notes
Neck
Normal
Abnormal
Not Examined
Back
Normal
Abnormal
Not Examined
Shoulder/arm
Normal
Abnormal
Not Examined
Elbow/forearm
Normal
Abnormal
Not Examined
Wrist/hand/fingers
Normal
Abnormal
Not Examined
Hip/thigh
Normal
Abnormal
Not Examined
Knee
Normal
Abnormal
Not Examined
Leg/ankle
Normal
Abnormal
Not Examined
Foot/toes
Normal
Abnormal
Not Examined
Please describe any abnormal findings.
Is there any other pertinent information concerning this individual's health that we should be aware of?
Participation
If accepted, this individual can participate in all activities at Camp Grassick with NO RESTRICTIONS.
If accepted, this individual can participate in all activities at Camp Grassick WITH RESTRICTIONS.
Please explain the restrictions.
Physician's Signature
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Date
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Month
-
Day
Year
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Name of Clinic/Hospital
Physician's/Clinic's Phone Number
Please enter a valid phone number.
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