2016 Sigma CO Information

SIGMA
Summer Information
2016
www.S kyR anch.org
903.266.3300
Index
Welcome from Linda S. Paulk .......................................................................................................................................3
Welcome from John Morgan........................................................................................................................................4
Sigma Program Overview...............................................................................................................................................5
Getting Ready Checklist...................................................................................................................................................6
Packing Tips..........................................................................................................................................................................6
What to Bring and What NOT to Bring.......................................................................................................................7
Sigma Night Events...........................................................................................................................................................8
Arrival, Departure, and Transportation Information.............................................................................................9
Contact Information.......................................................................................................................................................10
Stay Connected with Sky Ranch Social Media.......................................................................................................10
Health Information..........................................................................................................................................................11
General Guidelines and Policies.................................................................................................................................13
LifeMap................................................................................................................................................................................14
Physician’s Form...............................................................................................................................................................15
2
Welcome from our President & CEO, Linda S. Paulk
Dear Camper Parents,
Thank you for providing Sky Ranch the opportunity to serve your family this summer. It has been a privilege to
serve families for more than 60 years, providing a fun, Christ-centered encounter for all of our campers. We are
so excited about what God has planned for summer 2016 at Sky Ranch.
It is our desire to communicate effectively with all of our families in an effort to manage your expectations,
answer your questions, and provide you with peace of mind, knowing that your child is in great hands at Sky
Ranch. Within this packet, you will find up-to-date information, FAQs, and other material that will be helpful as
you and your children prepare for their week at Sky Ranch.
Please read the information carefully. Once you have had a chance to review the materials, please do not
hesitate to contact our Guest Services department at 903-266-3300 with any additional questions or concerns
you might have.
Thank you again for selecting Sky Ranch for your child’s camp experience. We are looking forward to a terrific
summer. Please know that it is an honor and a pleasure to provide an environment where your children can
relax, have fun, build life-long relationships, and most importantly, learn how to be the full expression of what
God has created them to be!
See you soon!
In His Grip,
Linda S. Paulk
President and CEO of Sky Ranch Camps
3
Letter from Team Leaders
Welcome to Sigma!
We are so excited for this summer and the incredible experience you are about to begin. These weeks will be
spent living in deep fellowship, enjoying hilarious moments, relaxing, playing, and delving into what it really
means to lead and live on mission. We’ve been praying and preparing all year for this and can’t wait to spend
time with you in colorful Colorado!
From the moment we begin investing in the lives of campers, we do so with a hope that one day they will
become a Sigma. Our Life Map program exists to build and equip servant leaders. It begins with the Morph and
Quest programs and culminates in the Sigma experience. A few campers that go through the Life Map accept
this challenge and you are one of them. Sigma will challenge you to grow in your faith and to grow as a leader.
Sigma is the kind of experience that makes you laugh and think. It’s the kind of experience that wears you out
and builds you up - the kind of experience that is deeply satisfying and ultimately life-changing.
So read through this packet and get prepared for an amazing summer!
You then, my son, be strong in the grace that is in Christ Jesus. And the things you have heard me say in the presence of many
witnesses entrust to reliable people who will also be qualified to teach others. Join with me in suffering, like a good soldier of Christ
Jesus. No one serving as a soldier gets entangled in civilian affairs, but rather tries to please his commanding officer. Similarly, anyone
who competes as an athlete does not receive the victor’s crown except by competing according to the rules. The hardworking farmer
should be the first to receive a share of the crops. Reflect on what I am saying, for the Lord will give you insight into all this.
1 Timothy 2:1-7
John Morgan
VP of Ministry Programs
Max Heller
Leadership Camp Manager
4
Sigma Program Overview
Sigmas will spend time every day exploring critical ideas, lifestyle choices, and principles which shape the
hearts and minds of effective leaders. Among other faith building activities, they will complete the following
leadership development modules:
Christ-like Character:
The Study of Principle Driven leader
Lifestyle of Service:
Leadership Principle: Earned Authority vs. Positional
Servant Leadership:
My Project Exercise: Understanding what I bring to the mission
Excellence:
The Art of Getting Things Done & Tenacity
Each day will be filled with time for plenty of fun and fellowship, the Sky Ranch way! Every day offers
something a little different than the day before. Your students can expect to enjoy these and many more fun
adventures during their stay at Ute Trail:
Ropes Courses
Barn Dance
Guys Night/Girls Night
Mission Impossible
Waterslides
Colorado Campout
Special Events
The Urban Exegesis: LIVING ON MISSION
Each year, Sigmas take a road trip meant to open their eyes to a proactive, solution oriented way of thinking.
One of the core values of the Sigma community is to live life “on mission.” But how do you know what that
mission is? How do you effectively engage the culture and community around you? The first step is to look for
what God is doing in the world and then follow His lead. This year Sigmas will take a pit stop on their way back
to Texas for a road trip we are calling the URBAN EXEGESIS.
An “exegesis” usually refers to a critical analysis of a text. However, in this case, we will apply our minds to the
analysis of a mission problem and the leadership required to overcome it. In order to do this, we will spend a
couple of days with the leaders of Open Door Ministries in Denver. See www.odmdever.org for more information on this ministry. The mission of Open Door Ministries is to “embrace the needy and broken people of
Denver with the heart and hands of Jesus.” Since 1984, they have provided practical help and hope to the
homeless and poor families of Denver. Through programs such as childcare, preschools, skill training, counseling, and meal services, ODM is an example of “living life on mission.”
Through hands-on participation in this mission, dialogue with the ODM leadership, and critical analysis with
their counselors, this experience will challenge each student to be a proactive contributor to the problems in
their community. They will learn from effective leaders how to turn compassion into action. In this very safe,
controlled environment, and with their Sky Ranch counselor sand leadership team, students will explore what it
means to truly “take on the nature of a servant” as they experience a world out there in need of their leadership.
5
Getting Ready Checklist
Please be sure that all of these items are completed before your camper attends camp.
Complete the Health Form ONLINE - through the Parent Portal at www.SkyRanch.org/Register
You must also have a physician's medical examination - complete and return to Sky Ranch.
Your camper will NOT be allowed to participate without a completed physical.
Complete the medication form and bring it with you to check-in.
Review the packing list and purchase necessary items or things for night events.
Arrange for care package(s) to be sent to your camper (most campers will receive mail, email, and
packages during the week).
Pay balance for camp in full.
Add money to the Ranch Bank Store Card.
Order your Sigma Sky Pack.
Remember to bring your driver’s license to camp - it’s required to drop off your camper!
As always, if you have any questions or concerns that are not addressed in this packet, please feel free to call
Guest Services at 903-266-3300 or email us at guestservices@skyranch.org.
Packing Tips
As you prepare for Sky Ranch Summer Camp, we have provided a list of items you will need to pack for your
camper. On the following pages, we’ve included extensive lists for “What to Bring” and “What NOT to Bring”.
Before we jump into packing, we wanted to share a few tips.
Helpful Hints
You are traveling by charter bus, so space is limited. Therefore, each camper is limited to 1 large duffle
bag or suitcase (not to exceed 50 lbs.), a sleeping bag, and a carry-on backpack. NO TRUNKS, please.
Don't buy a lot of new clothing - this is camp, and we will most likely get wet and dirty!
Use ziplock bags to waterproof items.
Don't send anything that you consider irreplaceable.
Clearly and boldly label all of your child's belongings.
Strapless clothing, mini-skirts, or t-shirts with large cut outs are not allowed.
All shorts must be a modest length (fingertip length) and we have a NO ROLL rule.
6
What to Bring and what not to bring
Please make sure that you clearly and boldly label all of your camper's belongings. Also, in order to ensure a
safe environment for our campers, we ask that you please do not bring cell phones, laptops, or dvd players.
Any smart phone or web enabled device is not allowed during the two week Sigma experience. Any
electronic device that could break easily or be stolen is not recommended. However, if a camper chooses to
bring an iPod or mp3 player for the trip, Sky Ranch cannot be responsible for stolen or broken articles.
Clothing
• Daily temperatures average about 75 degrees. Nights can dip to 30. Please pack enough clothing for
two weeks, as there is no laundry service during the session.
• A good piece of outerwear is essential, such as a lightweight jacket or fleece
• Rain jacket or poncho - very necessary
• One-piece swimsuit for water activities
• Sturdy shoes for hiking, and an older pair of tennis shoes for daily use
• Water shoes - either sandals with back straps or shoes that can get wet
• Western clothes (it wouldn't be Sigma without a Barn Dance!)
• Baseball cap or hat and sunglasses
• Blue jeans or long pants - - shorts for warmer days
• Socks, underwear, pajamas
• T-shirts/Tops: both long and short sleeves
• Night Events: See Page 8
Camp Life
• Warm bedding - we recommend a 20 degree rated sleeping bag and a pillow.
• Flashlight/Head lamp and watch
• Snacks for the bus ride and $20 for breakfast on the way up and back. You will have a Ranch Bank and
meals on camp, but not on the bus.
• BIG DEAL!!! Please remember your Bible, a journal (spiral notebook is fine), and pen
• Sunscreen, bug spray, and toiletries (shampoo, toothpaste, etc.)
• Disposable camera, stationary, and stamps
• 2 towels (for shower and river) and a wash cloth
• **WATER BOTTLE** As campers move up into the mountains, drinking plenty of water will help them
avoid altitude sickness. Please make sure your camper comes onto the bus with a large, full water
bottle or at least two bottles of water. It is recommended to bring two if possible.
For information on how to contact your camper in the case of an emergency please refer to Sky Ranch Horn
Creek Contact Information in this packet. Sky Ranch also provides www.skyranch.org/tracksigma for you to
locate your child during the bus trip and several areas of social media to keep you connected with your child
during camp. For more information please refer to www.skyranch.org/media.
7
SIGMA NIGHT EVENTS
Monday Night: Opening Show
As the Sigmas arrive at Horn Creek, we will have our own opening show, smaller than what you are used to in Van but all
the same fun and more interaction. This is a great way to get to know your counselors and for them to get to know you.
Tuesday Night: Soda Shop Night
We will be hanging out in the Horn Creek Rec Center with a wood basketball court, four lanes of bowling, a racquetball
court, climbing wall, and the soda shop. Come ready to listen to 70’s music as we throw back to the days of soda shops
and hang out.
Wednesday Night: Mission Impossible
This is the classic Van, TX night event with a twist. Our group is smaller and we are on the side of a mountain but the
mission is still the same: Defeat Myrtle and destroy her plan to take over camp.
Thursday Night: Barn Dance
It wouldn’t be Sigma without a barn dance and we will be dancing the night away. Think plaid shirts, cowboy boots,
corduroy pants, suspenders, and dark-rimmed glasses. Bring your best dance moves and get ready to enjoy a night of
two-stepping and root beer floats.
Friday Night: Girls/Guys Night
Girls: Bring flannels, jackets, and warm socks as we hangout along the mountain side.
Guys: Come ready for a night of hanging out as the men of Sigma.
Saturday Night: A Night at the Oscars
This will be an experience in the fine arts as the Sigmas get in their small groups to create a short play. Props will be
provided but feel free to bring your own as the winner will be getting an oscar.
Sunday Night: Colorado Campout
Horn Creek is set on the side of a mountainin beautiful Colorado so it just makes sense that we would spend one night
under the stars. We will make s’mores, play some guitar, and maybe play some campfire games as we enjoy a cold
Colorado night.
Monday Night: Coffee Haus
With low key music playing in between performers, this will be our most relaxed night event as we have an open mic and
open stage for people to show off their talents. Come prepared to imagine you are drinking a fine German coffee as you
sip hot chocolate and imagine the delicacy of German chocolate as you nibble on a Hershey’s bar.
Tribal Competitions: Zulu vs. Maasai
The legend continues in the mountains of Colorado with the tribes of Zulu and Maasai. Represent your tribe with pride by
wearing the color of the ocean (Zulu-Blue) and the color of the desert (Maasai-Red). If you have not yet been inducted
into a tribe, bring something of each color because you’ll be inducted in to your tribal family once you are here. Your
destiny awaits as you enter the final phase and earn your spot as one of the tribal legends.
8
Arrival, Departure, and Transportation Information
CHECK IN will take place on Sunday at Sky Ranch in Van, Texas.
• 24657 CR 448 Van, TX 75790
• Check-in begins at 4:00 pm.
• Sigmas will enter camp through the main gate – you will receive a luggage tag at the
black & white arm.
• Sigmas will meet their counselors at the Activity Center (next door to Legacy)
• Campers will have dinner, attend Opening Show, then load the bus and depart for Horn Creek by
10:30pm.
CHECK OUT will take place on the second Saturday at Sky Ranch in Van, Texas.
• The bus will depart Colorado on Thursday at 4:00 pm and will arrive at Sky Ranch, Van, Texas,
on Friday morning after breakfast. Sigmas will participate in special activities on Friday.
• Saturday, 9:30 am - Parents check in and pick up luggage.
• Saturday, 10:30 am - Join us for Closing Ceremonies with Sky 3 & 4.
Campers will travel by charter bus. They will need to bring their own snacks for the trip and about $20 for a meal on
the way up and the way back.
Track the Bus
You will be able to track your student's travel throughout their trip. Staff will be checking in with their GPS
locator every 30 minutes or so for travel updates. Please follow this link to see the bus' location:
http://www.SkyRanch.org/TrackLeadershipCamp
If you have additional questions about transportation, please feel free to call our Guest Services department at
903.266.3300.
Delays
Leadership staff on the bus will contact Leadership Camp Manager, Max Heller, if there are any serious delays
in travel due to weather, emergencies, or other unforeseen situations. Parents will be notified by phone if
there is any emergency involving the bus. Head counts of campers and staff are taken any time the bus stops.
Rules
All campers are required to follow the guidelines and rules explained by the bus driver for the charter bus
company and implemented by the camp leadership staff.
Maps and Directions
Maps and Directions to Sky Ranch locations are available on our website at www.SkyRanch.org/Locations.
9
Sky Ranch horn creek Contact Information
Year-Round Contact
Emergency Contact
(June through August)
Max Heller
Leadership Camps Program Manager
MaxH@SkyRanch.org
Becca Steffenson
Summer Camp Operations Manager
RebeccaS@SkyRanch.org
Sky Ranch Guest Services
Sky Ranch
24657 CR 448
Van, TX 75790
Phone: 903-266-3300
Sky Ranch Horn Creek
6758 County Road 130
Westcliffe, CO 81252
Phone: 719-783-2205
Fax: 719-783-2547
Stay Connected with Sky Ranch Social Media
Stay Connected During Camp Week (and All Year Long!)
Sky Ranch has an active presence in several areas of social media. You can find our official Sky Ranch fan pages
on Facebook, follow us on Twitter, and stay connected with us through a variety of blogs.
Please visit www.SkyRanch.org/Media to view the variety of ways you can communicate with us, get to know us
better, and stay connected all year long.
10
Health Information
Every Sky Ranch camper is required to fill out the Sky Ranch Health Form online in the Parent Portal. This should
be completed prior to your session start date. Please go to our Parent Portal to complete.
Special Dietary Requirements
Sky Ranch is concerned about your child’s health and will gladly work with you regarding special dietary restrictions and requirements. We can accommodate a gluten-free or dairy-free diet. Please contact Sky Ranch’s Food
Service Department by emailing RebeccaS@SkyRanch.org or calling 719-783-2205 to review our menu and
make the appropriate substitutions if available.
Lice Policy
For the safety, health and comfort of all campers, no child with untreated lice (bugs) or lice eggs (nits) on their
person or belongings will be admitted to camp. Each child will be checked for lice/nits upon arrival to camp. If
lice/nits are present, they must be treated prior to admittance to camp. Parents are responsible for treatment of
both their camper’s belongings camper’s head when lice and or nits are found at camper check-in. Please check
your child within 48 hours of arriving at camp (see www.headlice.org for more information). In order to properly
perform a lice/nit check, ponytails must be removed prior to check. We will do our best to do lice checks around
braids but any signs of lice or nits will require that braids be taken out. In the event that lice/nits are found, you
may choose to have Sky Ranch perform a lice/nit treatment on your child for a fee of $300.
Health Care Reminders
At Sky Ranch, safety is our number one priority. Your child’s safety and health are of the utmost importance to
us and we will provide professional and responsible care while they are at camp. To maintain our standards of
excellence, we follow the regulations for Colorado and Texas Youth Camps, and subscribe to the American
Camp Association standards. Below are some suggestions that will improve your child’s experience and expedite your check in process on Sunday.
• We have a No Nit, No Lice policy. Please inspect your child (ren) 48 hours prior to camp for lice and/or
nits. If found, please treat and remove ALL nits so that they can be admitted to camp. (There are a
number of resources available that can assist you in this process. For your convenience, here is a
sample website you can review: http://www.wikihow.com/Check-a-Child's-Hair-for-Lice.) Please note
that every child is also checked on their arrival day by a counselor and/or Health Care Professional.
• All medications are required to be in the original packaging and contain only the medication identified
on the container. Do not put two or more different medications in the same container.
• If your child requires a prescription medication, the prescription label must be legible with the camper’s
name on it. Please do not use old bottles or those belonging to another family member as they will not
be administered per state law.
• Please check the medication’s expiration date. Expired medication will not be administered per state law.
• The ONLY medications that are permitted to be kept with the counselors are RESCUE inhalers and EPI
pens. These are the only medications that our counselors are trained to administer. If you have any
questions, please feel free to contact our Health Care Administrator prior to camp. We do not allow
campers to keep these medications themselves as it poses a threat to other campers. A counselor that
has your child’s rescue medication will be with your child at all times. The counselors are allowed to
keep glucometers.
11
• Please contact the camp Health Care Administrator as soon as possible at GuestServices@SkyRanch.org
if your child has one or more of the following conditions:
• Requires any injectable medication
• Any seizure disorder
• Autism
• Asperger’s Syndrome
• Any special situation that requires our attention. It is very beneficial for us to have this information as soon as possible so that we may prepare our counselors and staff.
• If your child’s medication will be coming with someone who is not familiar with the dose and administration time, please be sure to send a note with the exact information. Medication administration times
are 30 minutes prior to and 30 minutes after Breakfast, Lunch, Dinner and at Bedtime. Please choose
which med call times you will prefer.
• If your child has surgery, a fracture or serious injury within six weeks of camp, please contact our Health
Administrator as a physician’s release will be required
• If contagious illness 7 days prior to camp, please contact Health Care Administrator to discuss specifics..
• All medications will be returned on Saturday. Medications that are left over are disposed of so please
be sure to stop by our Medication Return table in Legacy on Saturday.
Please feel free to contact our Health Care Administrator at GuestServices@SkyRanch.org with any questions.
12
General Policies and Guidelines
Cancellations
Campers who cancel before April 15, 2016 will be refunded all payments except the non-refundable deposit of
$200. If this reservation is cancelled for any reason after April 15, 2016, all monies paid will be non-refundable.
All cancellation requests must be submitted via e-mail to GuestServices@SkyRanch.org. All payments are
non-transferrable. Registrations not paid in full by April 15, 2016 may be subject to automatic cancellation.
Communications
The best way to contact Sky Ranch is through e-mail. Please address all correspondence to
GuestServices@SkyRanch.org. We check our e-mail regularly and respond in a timely manner. You may also call
903-266-3300.
Camper Check-Out Policy
Campers will be released only into the care of their parent or legal guardian. Before you pick up your child, you
will be required to show your driver’s license to our check-out staff and place your signature on the check-out
form. No camper will be released to any individual for any reason without following this check-out policy. Your
camper will only be released to authorized individuals listed in your Parent Portal under the “Additional
Questions” tab. We will not release your child to anyone not on this online list.
Ranch Bank Store Card
Upon arrival at camp, each camper is issued a Ranch Bank account. The Store Card helps campers control their
spending money. Because campers are not permitted to carry cash, each parent can deposit spending money
into their camper's account through the Parent Portal. Campers can purchase snacks, souvenirs, gifts, books,
apparel, toiletries and much more. We recommend depositing $120 for the Sigma session. Unused Store Card
funds may be donated to the Sky Ranch Scholarship Program once camp is over or credited back
approximately two weeks after camp is over.
Contacting Your Camper
If an emergency arises you can call our office 24 hours a day and one of our staff will assist you. If your camper
needs to contact you we will facilitate that as well. “I know my child is doing great, it’s me that is lonely!” We
understand... here is a tip - send an e-mail or letter to your camper. **If you plan to provide mail for your
camper, we HIGHLY RECOMMEND bringing it with you to camp and our counselors will deliver it on the day
you specify. Due to the mobility of Sigma and the delay in mailing between states, we do not recommend
sending mail in the traditional manner. Please keep in mind, there is limited space on the bus, so please keep
your packages reasonable in size.
We also enlist a third-party provider to process our emails (hundreds per day) and kids love it! Your e-mail will
be delivered directly to your camper with the daily mail call. This service is optional and will incur an additional
fee from the provider. More information will be provided at Check-In or you may visit www.SkyRanch.org for
complete details.
13
The Sky Ranch LifeMap
At Sky Ranch, we are honored to have the opportunity to impart solid Christian principles and the Word of God
into your child’s life. Sky Ranch’s faith and character development program is divided into three parts, and it’s
called the LifeMap. As your child grows older, he or she will progress through each phase until the completion
of the program.
Phase 1: Learn
Beginning with our first-time campers and going through the early teen years, Phase 1 creates a culture where
kids learn foundational concepts that build strong character and vibrant faith.
Phase 2: Experience
In Phase 2 camps students begin the C.O.R. Leadership Track based on I Corinthians. These camps are designed
to stand alone or tie together over the course of six summers to help develop a deep faith and the character of
a servant leader. Campers are challenged to dig deeper beyond their childhood beliefs as they begin to challenge their thinking and their faith. Phase 2 is an immersion into experiences that help turn teens into
Christ-centered servant leaders.
Phase 3: Become
As young adults, some campers choose to become counselors. Phase 3 is the fusion of content, context, and
the work of the Holy Spirit in the lives of young adults as they prepare for their adult years, all while giving back
to the next generation of children.
It is our hope that the Sky Ranch program can have an eternal impact on your child’s life by being an instrumental element of their spiritual and personal growth. We hope each phase will challenge them and help them
move forward to become the person God created them to be.
experience
learn
become
14
Sky Ranch Physician’s Medical Examination
A medical examination is REQUIRED for any participant attending any part of their camp session in Colorado
WĂƌƟĐŝƉĂŶƚ͛ƐEĂŵĞ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺK͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
,ĞŝŐŚƚ͗ͺͺͺͺͺͺͺͺͺͺͺͺtĞŝŐŚƚ͗ͺͺͺͺͺͺͺͺͺͺͺͺůŽŽĚWƌĞƐƐƵƌĞ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺWƵůƐĞ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
dŽWŚLJƐŝĐŝĂŶ͗^ŬLJZĂŶĐŚŝƐĂĐĂŵƉŝŶŐĞdžƉĞƌŝĞŶĐĞƚŚĂƚŝƐŽŶĞŽƌŵŽƌĞǁĞĞŬƐŝŶĚƵƌĂƟŽŶ͘WĂƌƟĐŝƉĂŶƚƐŵĂLJĞŶŐĂŐĞŝŶƐƚƌĞŶƵŽƵƐĂĐƟǀŝƟĞƐĚƵƌŝŶŐƚŚĞŝƌƐƚĂLJ͘dŚĞƐĞĐĂŶ
ŝŶĐůƵĚĞ͕ďƵƚĂƌĞŶŽƚůŝŵŝƚĞĚƚŽƌŽĐŬĐůŝŵďŝŶŐ͕ƌĂƉƉĞůůŝŶŐ͕ƌŽƉĞƐĐŽƵƌƐĞ͕ǁŚŝƚĞǁĂƚĞƌƌĂŌŝŶŐ͕ŚŝŬŝŶŐďĂĐŬƉĂĐŬŝŶŐ͕ĂŶĚŬĂLJĂŬŝŶŐ͘^ŬLJZĂŶĐŚĐĂŵƉƐŝŶŽůŽƌĂĚŽĂƌĞŝŶ
ĞdžĐĞƐƐŽĨϴ͕ϯϬϬĨĞĞƚŝŶĞůĞǀĂƟŽŶ͘tĞƌĞůLJŽŶLJŽƵƌĞǀĂůƵĂƟŽŶƚŽĚĞƚĞƌŵŝŶĞŝĨƚŚŝƐƉĞƌƐŽŶŝƐƉŚLJƐŝĐĂůůLJĐĂƉĂďůĞŽĨĂƩĞŶĚŝŶŐƚŚŝƐĐĂŵƉ͘
PHYSICAL EXAM
WNL
Abnormal
(Please describe abnormal findings)
,Ed
,ĞĂƌƚ
>ƵŶŐƐ
ďĚŽŵĞŶͬWĞůǀŝƐ
^ŬŝŶ
EĞĐŬͬĂĐŬ
hƉƉĞƌĞdžƚƌĞŵŝƟĞƐ
>ŽǁĞƌĞdžƚƌĞŵŝƟĞƐ
HISTORY OF:
Yes
No
Yes
,ĞĂƌŝŶŐŝƐŽƌĚĞƌ
KƌƚŚŽƉĞĚŝĐ/ŶũƵƌLJŽƌŝƐŽƌĚĞƌ
sŝƐƵĂůŝƐŽƌĚĞƌ
,ĞĂƌƚDƵƌŵƵƌͬ/ƌƌĞŐƵůĂƌŚĞĂƌƚďĞĂƚ
,ĞĂƌƚŝƐĞĂƐĞ
ŝnjnjŝŶĞƐƐǁŝƚŚdžĞƌĐŝƐĞ
^ƚƌŽŬĞ
,ĞĂĚĂĐŚĞƐ
,ŝŐŚůŽŽĚWƌĞƐƐƵƌĞ
tĞŝŐŚƚ>ŽƐƐͬŶŽƌĞdžŝĂͬƵůŝŵŝĂ
ŝĂďĞƚĞƐ
ŶƵƌĞƐŝƐ
^ĞŝnjƵƌĞƐ
ĞĞŶŚŽƐƉŝƚĂůŝnjĞĚŝŶƚŚĞůĂƐƚLJĞĂƌ
ƐƚŚŵĂͬ^ŚŽƌƚŶĞƐƐŽĨďƌĞĂƚŚ
WƐLJĐŚŽůŽŐŝĐĂůĐŽŶĚŝƟŽŶƐ
ůůĞƌŐŝĞƐƚŽŵĞĚŝĐŝŶĞ
ůůĞƌŐŝĞƐƚŽĨŽŽĚ
No
KƚŚĞƌŵĞĚŝĐĂůĐŽŶĚŝƟŽŶƐ͗
/ĨLJĞƐƚŽĂŶLJŽĨƚŚĞĂďŽǀĞ͕ƉůĞĂƐĞĞdžƉůĂŝŶ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
ჱzĞƐ‫܆‬EŽZĞƐƚƌŝĐƟŽŶŽŶĂĐƟǀŝƟĞƐ͍LJǁŚŽŵ͍ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
>ŝƐƚĂĐƟǀŝƟĞƐƚŚĂƚĂƌĞƌĞƐƚƌŝĐƚĞĚ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
dŚŝƐZĞƋƵŝƌĞĚWŚLJƐŝĐĂůdžĂŵŝŶĂƟŽŶĨŽƌŵŽƌŽƚŚĞƌWŚLJƐŝĐĂůdžĂŵĨŽƌŵŵƵƐƚďĞĮůůĞĚŝŶĂŶĚƐŝŐŶĞĚďLJĞŝƚŚĞƌĂWŚLJƐŝĐŝĂŶ͕ĂWŚLJƐŝĐŝĂŶƐƐŝƐƚĂŶƚ
ůŝĐĞŶƐĞĚďLJƚŚĞ^ƚĂƚĞŽĂƌĚŽĨWŚLJƐŝĐŝĂŶƐƐŝƐƚĂŶƚdžĂŵŝŶĞƌƐ͕ŽƌĂZĞŐŝƐƚĞƌĞĚEƵƌƐĞƌĞĐŽŐŶŝnjĞĚĂƐĂŶĚǀĂŶĐĞĚWƌĂĐƟĐĞEƵƌƐĞďLJƚŚĞŽĂƌĚŽĨ
EƵƌƐĞdžĂŵŝŶĞƌƐ͘džĂŵŝŶĂƟŽŶĨŽƌŵƐƐŝŐŶĞĚďLJĂŶLJŽƚŚĞƌŚĞĂůƚŚĐĂƌĞƉƌĂĐƟƟŽŶĞƌ͕ŝŶĐůƵĚŝŶŐĐŚŝƌŽƉƌĂĐƚŽƌƐ͕ǁŝůůŶŽƚďĞĂĐĐĞƉƚĞĚ͘
/ŶŵLJŽƉŝŶŝŽŶ͕ƚŚĞŚĞĂůƚŚŽĨƚŚĞŶĂŵĞĚƉĂƌƟĐŝƉĂŶƚĚŽĞƐŶŽƚƉƌĞĐůƵĚĞŚŝƐͬŚĞƌƉĂƌƟĐŝƉĂƟŽŶŝŶƚŚĞĂĐƟǀŝƟĞƐĂƚ^ŬLJZĂŶĐŚĐĂŵƉƐ͘
ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
WŚLJƐŝĐŝĂŶ͛ƐWƌŝŶƚĞĚEĂŵĞ
^ŝŐŶĂƚƵƌĞ
ĂƚĞ
/ĨƐŝŐŶĂƚƵƌĞĚĂƚĞĚŝīĞƌƐĨƌŽŵĚĂƚĞŽĨĞdžĂŵŝŶĂƟŽŶ͕ƉůĞĂƐĞƐƉĞĐŝĨLJ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
ϵϬϯ͘Ϯϲϲ͘ϯϯϬϬ
15
ŐƵĞƐƚƐĞƌǀŝĐĞƐΛƐŬLJƌĂŶĐŚ͘ŽƌŐ
ZĞǀŝƐĞĚϬϯͬϮϬϭϲ