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February 2016
Dear Physician,
Attached, you will find a physical evaluation form for one of your patients who intends on participating in
the Bolshoi Ballet Academy Summer Intensive, a rigorous ballet training program that includes a
minimum of about five hours of dance a day for either three or six weeks in an overnight or day capacity
(please ask your patient which applies to him/her). For more detailed information about our curriculum,
we encourage you to review our website www.bolshoiballetacademy.com.
We kindly request that you thoroughly and completely fill out all sections and fields of the evaluation.
Bear in mind that we rely extensively on your information to provide proper care for your patient while
enrolled in our program.
Thank you for your attention and for your help in ensuring the safety and well-being of our participants.
Should you have any comments, questions, or concerns, please do not hesitate to contact me.
Sincerely,
Alana Vogel
Assistant Director of RAF Youth Programs
Tel: 212-687-6118 ex. 208
Fax: 212-687-5558
Page 1 of 3
BBASI 2016 PHYSICIAN’S REPORT – MUST BE COMPLETED IN FULL BY THE PARTICIPANT’S REGULAR PHYSICIAN
PARTICIPANT’S PHYSICIAN’S REPORT (3 pages) – BBASI 2016 NOTE: THIS PHYSICIAN’S EXAMINATION MUST BE DONE WITHIN SIX MONTHS OF June 27th, 2016
Participant’s Last, First Name: ____________________________________________________Date of Birth (mm/dd/yyyy) ___/___/____
❏Full Session (6wks) ❏Session I (3wks) ❏Session II (3wks) Age on 6/27/2016:_______
❏Resident Student ❏Non-Resident Student
TO BE COMPLETED BY THE PARTICIPANT’S REGULAR PHYSICIAN (under care for at least 1 year). ALL INFORMATION MUST BE COMPLETE AND LEGIBLE / NO FIELDS LEFT BLANK.
❏MAY participate in all program’s activities (Please keep in mind the rigorous nature of the program which includes a minimum of 4.5
hrs of intensive ballet training Mon. – Fri., as well as additional activities. Sample schedule is available at www.BolshoiBalletAcademy.com).
❏MAY NOT participate in the following: (Describe any limitations or restrictions to activities):
____________________________________________________________________________________________________
___________________________________________________________________________________ Health History relevant information (including, but not limited to, emotional/social/behavioral/orthopedic concerns, surgeries, and/or physical limitations): Current Medical Concerns: ________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ The Participant is under the care of a physician for the following conditions: _______________________________ ___________________________________________________________________________________ Current treatment at the time of this report includes: ______________________________________________ ___________________________________________________________________________________ Does the Participant have any known allergies (food, drugs, plants, insects, etc.)? ❏No ❏Yes If you answered Yes, please list all known allergies:
If you answered Yes, do you consider any of these allergies CRITICAL? ❏No ❏Yes Which? If you answered Yes, and the Participant experiences an exposure, how should the allergic reaction be treated? ________________________________________________________________________________________________________________________________________________________________________________________________________ If there is an anaphylactic reaction, the parents of the Participant must supply an EpiPen – for BBASI CT only. For BBASI Prep and BBASI NY programs: Participants must have EpiPen on them at all times and be trained in self-administration.
Is the Participant trained in self-administration using an EpiPen? ❏No ❏Yes ___________________
Is Participant on a special diet? ❏No ❏Yes, Explain (use additional pages if needed): _____________________________
____________________________________________________________________________________________________
Does the Participant have any cardiovascular conditions? ❏No ❏Yes, Explain (use additional pages if needed): _______
____________________________________________________________________________________________________
_________________________________________________________________________________________________
Does the Participant have any respiratory conditions? ❏No ❏Yes, Explain (use additional pages if needed): _________
____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Any additional information about Participant’s behavior, physical, emotional, or mental health relevant to this Program: ___________________________________________________________________________________ ___________________________________________________________________________________
Page 2 of 3
BBASI 2016 PHYSICIAN’S REPORT – MUST BE COMPLETED IN FULL BY THE PARTICIPANT’S REGULAR PHYSICIAN
MEDICATIONS TO BE TAKEN BY THE PARTICIPANT DURING THE PROGRAM:
❏Participant will take NO prescription medications on a routine basis during the program.
❏ Participant WILL TAKE the following prescription and/ or OTC medication(s) during the program: NAME OF MEDICATION DATE START / END TAKEN FOR CONDITION ADMINISTERED AT DOSAGE METHOD/ROUTE
❏ breakfast
❏ lunch
❏ dinner
❏ other:__________
❏ breakfast
❏ lunch
❏ dinner
❏ other:__________
❏ breakfast
❏ lunch
❏ dinner
❏other:______
❏ breakfast
❏ lunch
❏ dinner
❏ other:__________
❏ breakfast
❏ lunch
❏ dinner
❏other:_________
NOTE ANY RELEVANT SIDE EFFECTS/REACTIONS TO MEDICATION: ___________________________________________
_________________________________________________________________________________________________
PLAN FOR MANAGEMENT OF SIDE EFFECTS/REACTIONS:___________________________________________________
_________________________________________________________________________________________________
IF ANY OF THE ABOVE-LISTED MEDICATIONS IS A CONTROLLED SUBSTANCE AS DEFINED IN THE DEA’S TITLE 21 CFR*,
PLEASE LIST HERE, AND SPECIFY THE RELEVANT CLASS:
*Office of Diversion Control, Title 21 Code of Federal Regulations can be read in full here:
http://www.deadiversion.usdoj.gov/21cfr/cfr/2108cfrt.htm
IMMUNIZATIONS AND TESTS
THE PARTICIPANT IS CURRENT ON HIS/HER AGE APPROPRIATE IMMUNIZATIONS AS PER THE GUIDELINES AND SCHEDULES SET BY THE CENTER FOR DISEASES AND CONTROL:
(please check one)
❏Yes ❏No
Please attach a copy of the Participant’s immunization record.
IMPORTANT: TB/PPD skin test and/or BCG vaccine: MANDATORY for all Participants outside of the U.S.
Page 3 of 3
BBASI 2016 PHYSICIAN’S REPORT – MUST BE COMPLETED IN FULL BY THE PARTICIPANT’S REGULAR PHYSICIAN
PHYSICAL EXAM (*Use additional pages if needed)
Normal Abnormal Ortho Normal Abnormal
Neurologic ❏ ❏ Neck ❏ ❏
Lymphatic ❏ ❏ Shoulders ❏ ❏
Heart ❏ ❏ Arms/ Hands ❏ ❏
Lungs ❏ ❏ Hips ❏ ❏
Abdomen ❏ ❏ Knees ❏ ❏
Genitalia/ hernia ❏ ❏ Feet/ Ankles ❏ ❏
Skin ❏ ❏ Other/ ❏ ❏
Please describe any abnormalities, if applicable: Blood Pressure: ___________ Pulse: ___________ Height: _______ Weight: _______ BMI Percentile*: ________
Vision Screening: Right ____________ Left____________ Hearing: Right______________ Left_______________
Postural/Scoliosis: ❏ No Spinal abnormality Spine abnormality: ❏Mild ❏Moderate ❏Marked ❏Referral made *Body Mass Index %, MUST BE COMPLETED
a
CONSENT FOR ACTIVITIES AND ADMINISTRATION OF MEDICATION
I have examined this Participant and have found his/her physical exam within normal limits,
except as previously noted. I have discussed with the Participant (and Guardian if under 18 yrs)
that s/he is applying to a rigorous and physically intensive program and hereby attest that s/he
is able to participate. I attest that the medication listed in this report, if any, may be
administered by the Program (CT only) or self-administered by the Participant (NY only) as per
my directions (above). I hereby further attest that this Participant has been under my care for
one (1) year or more. Print Name of Examining Physician: _______________________________________________________________
Phone # of Examining Physician (include country code if outside U.S.): ___________________________________
Address of Examining Physician: __________________________________________________________________
City/Town ______________________________State (Country) ______________________ Zip Code___________
Date of Exam (Must be within six months of June 27, 2016, mm/dd/yyyy): ____/______/_______
Signature of Examining Physician: ____________________________________________ License #:_____________
Date this form signed (mm/dd/yyyy): ____/______/_______
