CT Heart Camp Primary Care Provider

CT Heart Camp Primary Care Provider Physical Exam Form

TO BE COMPLETED BY PROVIDER'S OFFICE

You may download a copy of this form here. Uploads may be completed here.

Patient's First Name

Patient's Last Name

Patient's Date of Birth

Month

Day

Year

Date of Last Medical Visit

Month

Day

Year

Cardiac Diagnosis:

Surgeries or procedures for treatment of above cardiac condition:

Pacemaker

Anti-coagulants

Other Known Medical Diagnoses

General Appraisal (any symptoms currently)

Cardiac Restrictions (diet, activity, special needs, etc)

Is there anything else we should know regarding the camper’s cardiac risk in a camp environment?

Please include a copy of your last clinic summary with this form.

I have examined the person herein described and have reviewed his/her health history. It is my opinion that he/she is physically able to engage in camp activities, except as noted above.

Cardiologist Name

Cardiologist Signature

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CT Heart Camp Primary Care Provider Physical Exam Form

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