Pediatric clearance form 08252009
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  • 1. PEDIATRIC MEDICAL CLEARANCE FORMCCTT/RTEAMTM4986 Adams Rd, Suite ERochester, MI 48306Tel: 248-475-4844 ∙ Fax: 248-475-5777PATIENT INFORMATIONPatient First Name: ______________________________Last Name: ___________________________________Gender: Female Male D.O.B.: ___________________________ Email: ______________________Guarantor Name: ____________________________________________________ D.O.B.: ______________Address: ____________________________________ City: _________________ Zip Code: ____________Phone Number: _______________________________ Relationship to the patient: ______________________Health Insurance: _____________________________ Contract No. or Policy No.: ______________________THE FOLLOWING INFORMATION IS REQUIRED FOR PARTICIPATION IN THE PROGRAM:Physical Exam: (Information must have beenobtained within the last 12 months)Please attach copy of laboratory studies within thelast 12 months. Fax a copy of labs to 248-475-5777.Ht: ______Wt: _______ B/P: _______/________BMI: ___________ BMI%Age/Sex: _____________Waist Circumference: __________________________Skin Markings: _______________________________Other Finding:________________________________Required Lab Studies: Check if Done:Liver Function (SGOT and SGPT)Fasting GlucoseTotal CholesterolLDLHas the prospective participant been evaluated byany of the following for weight related issues? Ifyes, explain.HDLTriglyceridesOrthopedic ______________________________Endocrinology _____________________________Cardiology ________________________________Gastroenterology ___________________________Pulmonary ________________________________Behavioral Health __________________________Other: ___________________________________Optional Lab Studies:Thyroid Function(Free T4, TSH)Insulin LevelHemoglobin A1CCBCCreatinineBUNUrine ProteinUrine Glucose***MUST CHECK BOTH BOXES TO JOIN THE PROGRAM***Participant is cleared to join in exercise program.May participate in group sessions (R-Team™).***MUST CHECK APPROPRIATE DIAGNOSIS TO JOIN THE PROGRAM***V85.53 Body Mass Index, pediatric, 85thpercentile to less than 95thpercentile for ageV85.54 Body Mass Index, pediatric, greater than or equal to 95thpercentile for ageSecondary Dx/Other:REFERRING PHYSICIAN INFORMATIONPhysician Name (Please Print):Physician Signature: Date:Contact Name (person that fills out the form): Telephone:1806-01.09262012