Adult Health History Form - Western Pennsylvania
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2Completed Date:______________________
Adult Health History Form
Troop/Group #: _______________________
Received By: ________________________
Received Date:_______________________
GENERAL INFORMATION
Adult’s Name
Birth Date
/
/
Address
Street
City
State
ZIP Code
Emergency Contact Information (First/Last name)
Relationship
Phone
Alt. Phone
INSURANCE INFORMATION
Carrier Name
ID Number
Member Services Phone
Group Number
Address
Street
City
State
ZIP Code
Primary Care Physician
Primary Care Physician Phone
HEALTH CONDITIONS
Allergy
Reaction
Treatment
Date of Last Reaction?
Indicate in the space below any medical conditions (e.g., asthma, diabetes) that you have.
Yes
No
Is there a specific dietary regiment to follow? (If Yes, please provide details below.)
RECORD OF IMMUNIZATION
Date of last Tetanus vaccine
/
/
Select one of the following:
I attest that all of my immunizations are up to date.
I attest that I have not received immunizations. Note: Please contact to obtain and complete
an immunization waiver. The waiver is required for participation.
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Parent category: Medical