Clinical Reference Systems: Pediatric Advisor 10.0

 

Child's name ___________________________________________________ 

Diagnosis ______________________________________________________ 

___ Please excuse from gym class (physical education) for ______ 
    days.  

___ Limited physical education with the following instructions: 

    _____________________________________________________________ 

    _____________________________________________________________ 

    _____________________________________________________________ 


Thank you.  


Physician's name ________________________________________________

Physician's signature _________________________  Date ___________ 

Physician's phone number __________________________