Girl Scout Health History Form printable pdf download

Girl Scout Health History Form

This health history is to be completed and signed by parents/guardians of girls. (Confidential)

Girl Name

Date of Birth

Age

Address

City

Zip

Troop #

Parent/Guardian

Phone

SS#

Home Address

City

Zip

Business Phone

Father

Mother

In Emergency Notify

Relationship to Girl

(Name)

Address

City

Zip

Phone #

Physician’s Phone #

Name of Family Physician

Family medical/hospital

Policy or Group No.

Insurance Carrier

Part 1: Illness and Injuries (check those that apply and give appropriate dates)

Chronic or Recurring Illness

( ) Ear Infection

( ) Bleeding/Clotting Disorders

( ) Hypertension

( ) Asthma

( ) Hearing Defect/Disease ( ) Musculoskeletal Disorders

( ) Seizures

( ) Diabetes

( ) Convulsions

( ) Epilepsy

( ) Motion Sickness

( ) Other (specify)___________________________ Date of last Tetanus shot or DPT____________________________

Date of Last Health Examination: ______________ Operations or Serious Injuries ______________________________

Were any complicating medical problems noted in last health exam?

( ) Yes

( ) No

Is girl currently under the care of a physician or psychologist?

( ) Yes

( ) No

Please explain any “yes” answers to the above questions. __________________________________________________

_________________________________________________________________________________________________

Part 2: Allergies (check those that apply and specify nature of allergic reaction)

( ) Animals

_______________

( ) Hay Fever _______________

( ) Pollen _______________

( ) Food

_______________

( ) Medication _______________

( ) Plants _______________

( ) Insect sting _______________

( ) Other ________________________________________________

List any other medical conditions. ______________________________________________________________________

_________________________________________________________________________________________________

Part 3: Medications

Is your child currently taking any medication? ( ) Yes

( ) No

If yes, describe the condition/disease and the medication

and dosage she is taking. ____________________________________________________________________________

_________________________________________________________________________________________________

Girl Scout Leaders and/or Adult Volunteers are permitted to dispense medications, aspirin, Tylenol, and other drugs,

provided by parents ONLY WITH WRITTEN PARENTAL INSTRUCTIONS. All medications are to be given to the

leader/adult volunteer in their original containers; none are to be with the Girl Scout for self-administration.

I know of no reason(s), other than the information on this form, why my daughter should not participate in prescribed

activities except as noted.

_________________________________________________________________________________________________

Signature of Parent/Guardian

Date Signed

Jupiter Service Center

Oakland Park Service Center

1224 W Indiantown Road

4701 NW 33

Avenue

Jupiter, FL 33458

Oakland Park, FL 33309

561-427-0177

954-739-7660

Girl Scout Health History Form

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