Girl/adult Health History Form
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1Girl/Adult Health History Form
This health history form is to be completed and signed by a girl’s parent/guardian or adult participant.
First Name ________________________ Middle Name _______________________ Last Name ____________________
Date of Birth _______________________ Day Phone _________________________Gender _______________________
Address _______________________________ City _________________________ State ________ Zip ______________
Medical Insurance Carrier _____________________________________ Policy/Group # ___________________________
Primary Physician Name __________________________________ Phone _____________________________________
Part I: Allergies (specify nature of allergic reaction)
Animals ________________________
Hay Fever _________________________
Medicine/Drugs ______________________
Food ___________________________
Insect Stings _______________________
Plants/Pollen ________________________
Other ______________________________________________________________________________________________________
Part II: Illnesses and Diseases – Chronic or Recurring
Arthritis
Diabetes
Measles
Sinusitis
Asthma
Ear Infection
Musculoskeletal Disorder
Tuberculosis
Bleeding/Clotting Disorders
Heart Defect/Disease
Rheumatic Fever
Other _________________________
___________________________
Chicken Pox
Hypertension
Seizures
Part III: Other Health Conditions
Bed Wetting
Fainting
Motion Sickness
Sleep Disturbances
Constipation
Hearing Impairment
Nosebleeds
Special Dietary Regimen
Emotional Disturbances
Menstrual Cramps
Sickle Cell Trait/Disease
Wear Glasses/Contact Lenses
Part IV: Immunization History
Immunization History is attached.
All immunizations are up-to-date.
Permission to give to participant:
Sudafed/Decongestant
Swimmer’s Ear or Alcohol/Vinegar Solution
Tylenol/Acetaminophen
Tums/Antacid
Robitussin/Expectorant
Benadryl/Antihistamine
Advil/Ibuprofen
None
Participant Statement: I certify that to the best of my knowledge this health history is complete and accurate. I know of no
reason(s) other than the information indicated on this form, why I/my daughter should not participate in prescribed activities except noted.
Privacy Statement: All health records will be handled by staff/volunteers whose job includes processing or using this
information for the benefit of the participant. This information will be held in limited access by the troop leader/healthcare supervisor of the
event. Minimal necessary information may be shared with event staff/volunteers in order to provide adequate safety and healthcare. I have
read the above information and agree to the release of any records necessary for treatment, referral, billing or insurance purposes.
Parent Authorization: If my child needs medical treatment, I authorize the adult in charge, should it be necessary, to secure the
service of a doctor at my expense. I give my permission for her to be attended for care. I am aware that I will be contacted in the case of
an emergency.
Parent/Guardian/Adult Participant Signature ______________________________ Date __________
Rev 03/2016 Operations
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