This information is approved and/or reviewed by U-M Health System providers but it is not a tool for self-diagnosis or a substitute for medical treatment. You should speak to your physician or make an appointment to be seen if you have questions or concerns about this information or your medical condition. Exención de responsabilidad en Español | Complete disclaimer
Child's name ______________________________________________
I performed a complete physical examination on this patient
on ________________.
Medical problems:
___________________________________________________________
___________________________________________________________
___________________________________________________________
___ This child is not contagious for any infectious diseases.
This child's allergies are: _______________________________
___________________________________________________________
This child's medications are: ______________________________
____________________________________________________________
___ This patient can participate in all sports and
activities OR
___ This patient should have limited activity as follows:
____________________________________________________________
____________________________________________________________
___ This patient can eat a regular diet OR
___ This patient has the following dietary restrictions:
____________________________________________________________
____________________________________________________________
Physician's name ___________________________________________
Physician's signature _____________________ Date ___________
Physician's phone number ____________________________
