Health History - Adult (Englsih And Spanich) Form
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1Girl Scouts of Northeast Texas
HEALTH HISTORY - Adult
HISTORIA DE SALUD PARA ADULTOS
INFORMATION
Name/Nombre _________________________________________________ Birth Date/Fecha de Nacimiento __________________
Address/Dirección _________________________________________________________________________________________
City/Ciudad __________________________________________________________ Zip/Código Postal_____________________
Person to contact in case of emergency/Notifique a:
Name/Nombre____________________________________________________________________________________________
Phone/Teléfono
(H)(_____________________________________________(B)(____)_____________________________________
Name/Nombre_____________________________________________________________________________________________
Phone/Teléfono
(H)(_____)_________________________________________(B)(_____)_________________________________
Physician/Médico________________________________________________Phone/Teléfono(________)____________________
Medical/Hospital Insurance Carrier
Policy/Group Number
Nombre
de la Aseguransa Médica__________________________________ Número de Póliza____________________________
HEALTH HISTORY
Immunizations: Last date given// Vacunas: Fecha de Últimas Vacunas
_______
Oral Polio/Polio
_______
Measles/Sarampión _______
Rubella/Rubela
_______
Mumps/Paperas
_______
DPT(Diptheria/Pertussis/Tetanus)/DPT(Dipteria/Tétanos)
Chronic/Recurring Conditions: Check all that apply// Condiciónes Crónicas: Marque los que aplican:
_______
Asthma/Respiratory Problems//Asma/Problemas de Respiratorio
_______
Epilepsy/Epilepsia
_______
Kidney Disease/Enfermedad de Riñon
_______
Headaches/Dolores de Cabeza
_______
Heart Disease/Enfermedad de Corazón
_______
Fainting/Desmayo
_______
Diabetes/Diabetis
_______
Nosebleed/Hemorragia Nasal
_______
Ear Infection/Infeciones del Oído
_______
Bleeding/Clotting Disorders/Problemas de Sangre
_______
Special Dietary Regimen/Dieta Especial
_______
Hypertension/Hipertensión
_______
Seizures/Ataques Apopléticos
_______
Constipation/Estrenimiento
_______
Emotional Disturbances/Problemas Emocionales
_______
Hearing Impairment/Dificultades en Oír Sordo
_______
Sickle Cell Trait or Disease/Tendencia del Sickle Cell Anemia
_______
Musculoskeletal Disorders/Desarreglo del Sistema
Musculoesceletal
_______
Other/Otra________________________________________
Date last examination/Fecha de último examen médico___________________________________________________________________________________________________
Are activities restricted?/ ¿Esta restringida su actividad física?
_______
No/No
_______
Yes/Si
If Yes, explain/ explique____________________________________________________________________________________________________________________________
Allergies: Check all that apply/ Alergias: Marque a los que son aplicable:
Animals/Animales
Plants/Plantas
Food/Comidas
Pollen/Polen
Insect bites/stings//Piquete de insecto/aguijon
Medicines/Drugs//Medicina/Drogas
Hayfever/Fiebre del Heno
Other/Otra
Current medication: specify
___________________________________________________________________________________________________________________
Medicina que toma actualmente: ___________________________________________________________________________________________________________________
Check if you wear:
Contact lenses
Glasses
Dental appliance
Other
Marque si usa:
Pupilentes
Anteojos
Auxilio dental
Otra
/aw rev. 4/09
N:\AW:\dtp\gaou\forms\2009 forms\health history adult.p7
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