Girl Scouts Of Western New York - Adult Health Form Page 2
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1
2CONFIDENTIAL
1.
Are you on any medication? _______
2.
State Medication and dosage. __________________________________________________________________
3.
Reasons for medication. ______________________________________________________________________
4.
Are you on a special diet? _____________________________________________________________________
5.
Please explain. _____________________________________________________________________________
6.
Do you have any allergies? ____________________________________________________________________
7.
Do you have asthma?________________________________________________________________________
8.
Are you diabetic? __________Do you take insulin? _______________
9.
Do you have high blood pressure? __________________
10.
Comments on any other health factors or conditions to which we should be alerted?
________________________________________________________________________________________________
________________________________________________________________________________________________
CONFIDENTIAL
1.
Are you on any medication? _______
2.
State Medication and dosage. __________________________________________________________________
3.
Reasons for medication. ______________________________________________________________________
4.
Are you on a special diet? _____________________________________________________________________
5.
Please explain. _____________________________________________________________________________
6.
Do you have any allergies? ____________________________________________________________________
7.
Do you have asthma?________________________________________________________________________
8.
Are you diabetic? __________Do you take insulin? _______________
9.
Do you have high blood pressure? __________________
10.
Comments on any other health factors or conditions to which we should be alerted?
________________________________________________________________________________________________
________________________________________________________________________________________________
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