Patient Medical Form printable pdf download

MEDICAL FORM

To be completed by every participant in any activity.

Please note that the activity leadership must have the ORIGINAL form. (Some hospitals will not accept copies).

Activities such as field days, day hikes and conferences and academies where medical staff is available a medical history is required but a physicians

evaluation is not required.

Activity such as resident camping, extended outings, hiking & boating in remote areas where medical staff is not readily available requires a physicians

evaluation (signature required on 2

page of this form)

PARTICIPANT INFORMATION:

(Required)

Group/

Post No

Local LFL Office No.

LFL Headquarters Ci t y

_______________________________ ________________________ ___ (

)

Last Name

First Name

Phone

_____

Address

City

State

Zip

Youth______ / Adult______

Registered as (Required):

Gender: Male______ / Female______

Age_____ / Birth Date____/____/________

Name of adult leader

participating in the activity who agrees to be responsible for this participant ___________________________________________________

Overnight Activities: All leaders must be registered as an adult with Learning for Life and provide male leaders for male youth participants and female leaders for female

youth participants.)

MEDICAL INFORMATION

Check all items that apply, past or present, to your health history. Explain any "Yes" answers.

Yes

ALLERGIES: Food, plants, medicines, insect bites

Explain:

GENERAL INFORMATION

Yes No

Asthma

Convulsions/seizures

Hemophilia

Attention Deficit/Hyperactivity

Diabetes

High blood pressure

Disorder (ADHD)

Cancer/Leukemia

Heart trouble

Kidney disease

Explain:

List any medications to be taken during the activity .

List ALL medications taken in the 30 days prior to arrival.

List any physical or behavioral condit i ons that may affect or limit full participation.___________________________________________________________________

List equipment needed such as wheelchair, braces, glasses, contact lenses, etc:

IMMUNIZATIONS (Date of last inoculation):

Chicken Pox

Lyme Disease (not required)

Pertussis

Rubella

Diphtheria

Measles

Polio

TetanusToxoid

Hepatitis B

Mumps