High Adventure Activity Medical Form

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High Adventure Activity Medical Form
This form is valid for 12 months.
This form should be kept at the Troop level.
Please attach to the AHG Health and Medical History Form.
Participant Name: ______________________________________ DOB: _____/_____/_____ Age: _________
Emergency Contact Name: ____________________________ Phone #: _____________________________
Health Examination: To be completed by a Licensed Health-Care Provider
The applicant will be participating in a strenuous activity that will include one or more of the
following conditions: athletic competition, adventure challenge, or wilderness expedition (afoot or
afloat) that may include high altitude, extreme weather conditions, cold water, exposure, fatigue,
and/or remote condition where readily available medical care cannot be assured.
Date of Exam: ____________________
Vision:
Hearing:
Height ____________ Weight __________
Normal __________
Normal: __________
B.P _______/_______ Pulse ___________
Glasses __________
Abnormal: ________
Contacts _________
Check box if normal; circle if abnormal and give details below:
Growth, development
Teeth, tonsils
Genitourinary
Skin, glands, hair
Respiratory
Skeletomuscular
Head, neck, thyroid
Cardiovascular
Neuropsychiatric
Eyes, ears, nose
Abdomen, hernia, rings
Other (specify)
Comments/Details: _______________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Dietary Restrictions
________________________________________________________________________________________
Approved for participation in:
___ Hiking
___Water Activities
___ Competitive Sports
___ All activities
Specify exceptions:
________________________________________________________________________________________
________________________________________________________________________________________
Page 1 of 2
Updated: January 2015

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