Forms2_Cardiology
Recommended Subacute Bacterial Endocarditis Prophylaxis
recommended subacute bacterial endocarditis prophylaxis
None
Standard
other
Check the letter below describing the level of exercise tolerance in which the applicant is able to participate.
full active participation with no restrictions
full active participation with moderate exercise
partial active participation with light exercise
limited active participation with no exercise
Allergies:
Medication/Trigger
Date of the last Reaction
Type of Reaction
Medication Trigger1:textfield
date of the last reaction1
type of reaction1
medication trigger2
date of the last reaction2
type of reaction2
medication trigger3
date of the last reaction3
type of reaction3
Medications:
Medication / Strength / SIG:
Special Instructions:
medication strength sig1
special instructions1
medication strength sig2
special instructions2
medication strength sig3
special instructions3
medication strength sig4
special instructions4
medication strength sig5
special instructions5
Non-prescription medications we stock in the camp infirmary are listed below: Please check those which we SHOULD NOT administer
non prescription medications
Acetaminophen
Advil
Benadryl
Caladryl
Chloraseptic Spray
Cough Medicine
Dramamine
Kaopectate
Meclazine
Milk of Magnesia
Pepto Bismol
Sudafed
describe any recent operations or serious illness
describe any physical disability effecting camp activity
describe any pertinent findings on examination
Cardiac Rhythm/Device History
does applicant have a history of dysrhythmias
Yes
NO
does applicant have a pacemaker or icd
Yes
NO
Pacemaker
pacemaker brand
pacemaker model
pacemaker programmed to
pacemaker mode
pacemaker lower rate
pacemaker upper rate
ICD
icd brand
icd model
has icd discharged recently and how often
Cardiac Transplant Only
date of transplant
surgeon
name of center
phone
evidence of rejection
Yes
NO
if evidence of rejection then type and grade
Physical Exam:
height
weight
heart rate
o2 saturation
Blood Pressures:
bp ra
bp la
bp rl
bp ll
Pulses:
pulses rue
pulses lue
pulses rle
pulses lle
cardiovascular
precordial activity
murmurs
neurological
lungs
abdomen
gi gu