Personal Health And Medical Record Form - Denver Area Council, B.s.a. printable pdf download

Denver Area Council, B.S.A.

Personal Health and Medical Record—Class 1 and Class 3

Instructions: This form is two sided. By completing only the front side, this form qualifies as a Class 1 medical history. A Class 1 medical history is

a brief health history that does not require a physician’s signature. A Class 1 medical history is required for all youth and adults to attend any

Denver Area Council event. By completing the front AND the back, this form qualifies as a Class 3 medical record. A Class 3 medical record is a

complete health history that requires a physician’s signature indicating that the youth or adult is fit to attend the event. A Class 3 medical record is

required for all youth and adults staying 72 hours or more at a Denver Area Council event. Youth and adults without a completed medical form will

not be allowed to participate and sent home. Please make copies of this form, as it will not be returned to you at the end of the event.

I. Personal and Emergency Contact Information

Name: __________________________________________________________________ Date of Birth:____________ Age:______ Sex:__________

Last Name

First Name

Middle Initial

Address: ________________________________________________________________ City / State:________________________ ZIP:____________

Name of Parent / Guardian or Spouse: ______________________________________________________

Phone #:___________________________

Place of Employment: ____________________________________________________________________

Phone #:___________________________

If person named above is not available in the event of an emergency, please contact:

Name: _________________________________________ Relationship: __________________________

Phone #:___________________________

Name: _________________________________________ Relationship: __________________________

Phone #:___________________________

Persons authorized to take youth from the event (include address and phone):

____________________________________________________________________________________________________________________________

Persons NOT authorized to take youth from the event (include address and phone):

____________________________________________________________________________________________________________________________

II. Health History / Information

Check all items of concern or that apply, past or present, to your health history.

Name of Primary Physician: ____________________________________________

[ ] Frequent Ear Infections

[ ] Hypertension

Primary Physician’s Phone #: ___________________________________________

[ ] ADD/ADHD

[ ] Convulsions/Epilepsy

Primary Physician’s Address: ___________________________________________

[ ] Mononucleosis

[ ] Drug Allergies

[ ] Heart Defect/Disease

[ ] Diabetes

City / State: _____________________________

ZIP: ______________________

[ ] Mumps

[ ] Bleeding/Clotting Disorders

Name of Dentist / Orthodontist: _________________________________________

[ ] Asthma

[ ] Chicken Pox

[ ] Kidney Disease

[ ] Insect Stings

Dentist / Orthodontist Phone #: _________________________________________

[ ] German Measles

[ ] Measles

Medical Insurance Provider: ____________________________________________

[ ] Hay Fever

[ ] Other Allergies (list below)

Carrier’s Name: ______________________________________________________

Explain all items checked above: _________________________________________

Policy or Group #:_____________________ Medicaid ID #: __________________

_____________________________________________________________________

Medications taken within last 30 days: ___________________________________

_____________________________________________________________________

____________________________________________________________________

Problems or diseases not mentioned above: _______________________________

____________________________________________________________________

_____________________________________________________________________

____________________________________________________________________

_____________________________________________________________________

Medications to be continued at event (with dosage): ________________________

Recurring illness or disability: ___________________________________________

____________________________________________________________________

_____________________________________________________________________

____________________________________________________________________

_____________________________________________________________________

____________________________________________________________________

Operations or serious injuries (dates): ____________________________________

Other Special Instructions related to Medications: __________________________

_____________________________________________________________________

____________________________________________________________________

_____________________________________________________________________

____________________________________________________________________

III. Parent / Minor Signatures

This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities except as noted.

Emergency Authorization: I hereby give permission to the medical personnel selected by the camp director to order x-rays, routine tests and treatment for me/or my

child, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treat-

ment for, and to order injection and/or anesthesia and/or surgery for me/or my child as named above. Permission is also given to transport me/or my child for medical

assistance. This form may be photocopied for use at camp. I understand that I am responsible for payment of all medical treatments received.

I also give permission for my child to go on trips away from camp premises, and to participate in all camp activities. I give the Denver Area Council, Boy Scouts of Amer-

ica permission to use photographs of my child for purposes furthering the mission of the Denver Area Council, Boy Scouts of America.

*** Signature of parent or Guardian (or participant if over 18): _____________________________________________________

Date: _____________________

Signature of Witness: ____________________________________________________________________________________

Date: _____________________

*** Signature of Minor: ______________________________________________________________________________________

Date: _____________________

***

YOU MUST HAVE THE ABOVE SIGNATURES TO ATTEND THE EVENT!!

***