Cardiologist Authorization and Health Inventory Form

Your patient is applying to attend Upbeat Hearts Camp, a specialized cardiac camp for children with heart conditions.

Your cooperation is requested to provide our medical staff and medical care providers with pertinent medical history regarding your patient.

The camp is scheduled for July 27 – 31, 2025.

The last clinic visit must be within 1 year of the application. In addition, a copy of the last clinic note is required.

Patient Name

Patient Date of Birth

mm/dd/yyyy

Cardiac Diagnosis or Diagnoses

Other Pertinent Diagnosis or Diagnoses

Surgical History (Please include the intervention and date)

Physical Exam

Date of Most Recent Visit

Height

Weight (kg)

Blood Pressure

SpO2 Range

Murmurs

Other Pertinent Physical Exam Finding

Is he/she required to carry an EPI Pen?

Yes

Does the patient have allergies to any medications, foods, or other things?

Yes

Prescribed Medication(s)

Please be specific

Format: Medication Name / Strength / Dosage / Frequency / Reason

Example: Tylenol / 250mg / 1 capsule / Every 8 hours/ Headaches

Do you recommend SBE Prophylaxis?

Yes

Cardiac Rhythm / Device History

Does the camper have a history of dysrhythmia?

Yes

Date of Last Episode

Does the applicant have a PACEMAKER or ICD?

Yes

Please send a copy of the last interrogation

You can attached at the bottom of this form

Activity Participation (Select One)

A: FULL ACTIVE PARTICIPATION WITH MODERATE EXERCISE- Participates in non-contact games, which may involve running short distances.

B: PARTIAL ACTIVE PARTICIPATION WITH LIGHT EXERCISE- Participates in limited activities. Camper rests occasionally.

C: LIMITED ACTIVE PARTICIPATION WITH NO EXERCISE- Must rest frequently and often. May participate in sedentary activities only.

**If camper fits Category C above, please reconsider his/her suitability for camp. If you perceive that this applicant may benefit from actively participating in our programs, please submit a written explanation

ADDITIONAL COMMENTS OR RESTRICTIONS:

Cardiology Form

We would like to thank you for helping us to make Upbeat Hearts Camp a safe place for children with heart conditions. If any event occurs while your patient is at camp, we will contact you as soon as possible, as instructed below:

Providers Statement

By checking this box I confirm I have examined the above named patient who is physically able to engage in camp activities except for the limitations and restrictions listed in the above form

Name

Phone Number

Phone

Please attach any documentation here

Drop your files here

Send me a copy of my responses

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