Boy Scout Application Packet (Page 7 of 7) in pdf

Class 1 Personal Health History

(Update annually, using form No. 34414.)

PLEASE DETACH BEFORE COMPLETING.

Identification: To be filled out by parent or guardian. Please print in ink.

Name_______________________________________________________________________________________________ Date of birth_____________________ Age_____

Name of parent or guardian_______________________________________________________________ Telephone_______________________________________________

Home address ____________________________________________________ City___________________________________ State________ Zip code________________

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

Allergies: Food, medicines, insects, plants Yes

Explain:________________________________________________________________________________________

■

General Information: Yes No

Yes No

ADHD (Attention Deficit

Asthma

Convulsions/seizures

Heart trouble

High blood pressure

■

Hyperactivity Disorder)

■

Cancer/leukemia

Diabetes

Hemophilia

Kidney disease

■

List any medications to be taken at camp: _____________________________________________________________________________________________________________

List any physical or behavioral conditions that may affect or limit full participation in swimming, backpacking, hiking long distances, or playing strenuous physical games:

_______________________________________________________________________________________________________________________________________________

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

Immunization or History of Having Had Disease (give date of last inoculation):

Tetanus toxoid______________

Pertussis _________________

Mumps___________________

Polio_____________________

Hepatitis A ________________

Diphtheria ________________

Measles__________________

Rubella __________________

Chicken Pox_______________

Hepatitis B _______________

Name of personal physician _____________________________________________________________ Telephone ______________________________________________

Personal health/accident insurance carrier_________________________________________________ Policy No. ______________________________________________

Parent Authorization:

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

illness or accident in the course of such activity, I request that measures be instituted without delay as the judgment of medical personnel dictates.

Signature ________________________________________________________________________________________________

Date _______________________________

Parent or guardian