Supplemental Medical Screening Questionnaire Template - Boy Scouts Of America printable pdf download

Boy Scouts of America

Camping and Outdoor Programs

Supplemental Medical Screening Questionnaire

This must accompany the BSA medical form for all campers

PART I – TO BE COMPLETED FOR ALL CAMPERS

NAME: ___________________________________________________ AGE ________

CAMP: ___________________ CAMPSITE: _________________ UNIT __________

Do you have any medicine, food, or environmental allergies? If so, please list them?

YES (please list)

Are you taking any medications prescribed by a doctor? If so, please list them below:

YES (please list and continue on back if necessary)

1. ______________________________

5. ______________________________

2. ______________________________

6. ______________________________

3. ______________________________

7. ______________________________

4. ______________________________

8. ______________________________

PART II – TO BE COMPLETED BY UNIT LEADER OF SCOUTS UNDER 18

As the adult unit leader for the Scout named above, I recognize that he is currently taking the

medication(s) listed above. I agree to take responsibility for these medications, including locking them

for storage, and making certain that the Scout takes them as prescribed.

X______________________________________ Date _____________________

If desired, medication can be stored and locked (refrigerated if necessary) in the camp Program Hall. In

this case, medication will be issued only to the unit leader for administration.

PART III – TO BE COMPLETED BY PARENT/GUARDIAN OF SCOUTS UNDER 18

Which of the following over-the-counter medications do you give permission for Health Services to

administer to your child, should they be needed throughout the week? All medications will be dosed

according to package instructions for his age (please circle):

acetominophen (Tylenol) YES NO

ibuprofen (Advil/Motrin) YES NO

diphenhydramine (Benedryl) YES NO

pseudoephedrine (Sudafed) YES NO

Pepto-Bismal YES NO

TUMS YES NO

Maalox YES NO

Milk of Magnesia YES NO

loperamide (Imodium AD) YES NO

Robitussin YES NO

tolnaftate (Tinactin) YES NO

Oragel YES NO

Parent’s Signature ______________________________________ Date ______________

______________________________________________________________________________

FOR MEDICAL STAFF USE ONLY:

Screening date: ___________ Screener’s initial’s ________

Meds stored in camp:

Supplemental Medical Screening Questionnaire Template - Boy Scouts Of America

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