Camper Personal Health And Medical Record Form - Class 3 printable pdf download

PERSONAL HEALTH AND MEDICAL RECORD FORM - Class 3

BOY SCOUTS OF AMERICA

PAGE 1 of 2

I. IDENTIFICATION: Age _________ Sex ________Date of Birth ___________

INSTRUCTIONS

Physical examinations for campers must have been completed within the previous 24 months.

Physical examinations for adults over 40 must have been completed within the previous 12

Name ____________________________________________________________

months. Parents must sign that the health history has been reviewed within the previous 12

months. Parents must complete all information on Page 1 of this form. Physician must com-

Address __________________________________________________________

plete all sections on Page 2, including the immunization record.

City&State ______________________________________ ZIP ______________

II. EMERGENCY MEDICAL INFORMATION:

Has or is subject to (check and give details):

Health / Accident Insurance __________________________________________

Allergy to a medicine, plant, food, plant animal or insect toxin.

Policy # __________________________________________________________

Any condition that may require special care, medication, or diet

ADHD (Attention Deficit Hyperactivity Disorder)

IN AN EMERGENCY NOTIFY:

Asthma

Convulsions

Heart trouble

Contact lenses

Name ____________________________ Relationship _____________________

Diabetes

Fainting spells

Bleeding disorders

Dentures

Daytime phone: ____________________ Evening phone: ___________________

EXPLAIN: ________________________________________________________

Cellular phone: ____________________ Pager: __________________________

_________________________________________________________________

Personal Physician: ___________________________Phone: ________________

_________________________________________________________________

III. MEDICATIONS TAKEN PRIOR TO CAMP

IV. MEDICAL HISTORY

List all prescription medications administered within the 30 days prior to arrival

Parent (or applicant, if over 18): Fill in sections I, II, III and V before seeing physician. Check

at the Scouting activity for which this form is used:

immunizations to be given at this time. Be sure to include any emergency information and

restrictions or special care that should be observed. Especially be sure to record any inju-

________________________________________________________________________

ries, illnesses, surgery, or significant changes in condition of health of applicant since last

complete examination.

________________________________________________________________________

• Date of most recent complete physical examination (month and year): _______________

_____________________________________________________________

• Are you aware of any current health problems?

Yes

V. PARENTAL/APPLICANT STATEMENT

• Now under medical care or taking medication?

Yes

• Has there been any surgery, injury, illness, allergy, or change in health

To the best of my knowledge, the information in sections I, II, III and IV is accurate and complete. I

request licensed health-care practitioner to examine applicant, to give needed immunization, and to

since last complete examination?

Yes

furnish required information to other agencies as needed. I give my permission for full participation in

BSA programs, subject to limitations noted herein. In the event of illness or accident in the course of such

• Has it been necessary to restrict applicant’s activities for medical

activity, I request that measures be instituted without delay as judgement of medical personnel dictates.

reasons?

Yes

I further authorize Yankee Clipper Council, BSA to use my or my son’s likeness in print or electronic form

for purposes consistent with the Aims of the Boy Scouts of America.

If you answered “Yes” to any of the above, explain: ______________________________

Parent or Guardian:

_____________________________________________________

________________________________________________________________________

(Must sign if applicant is under 18)

________________________________________________________________________

Applicant Signature:

_____________________________________________________

Give dates and full details below for any “Yes” answers.

Date Signed: _____________________________________________________________

IS THERE PAST OR PRESENT HISTORY OF:

VI. PERMISSION TO ADMINISTER MEDICATIONS

No:

Yes:

No:

Yes:

I give the camp health officer, or BSA registered unit leader (for activities other than sum-

Serious illness

Stomach, bowels

mer camp), or the designated health officer (for other activities) permission to administer

Serious injury

Appendicitis

the medications indicated by the licensed health-care practitioner on the reverse side

and such over-the-counter medications, including but not be limited to Tylenol, Advil, or

Deformity

Kidneys or urine

Benadryl as deemed necessary by the camp health officer, BSA registered unit leader (for

activities other than summer camp), or the designated health officer (for other activities).

Surgery

Albumin

Medications indicated under the allergies section of this form will not be administered.

Skin, glands

Sugar

Parent or Guardian:

_____________________________________________________

Ears, eyes

Infection

(Must sign if applicant is under 18)

Nose, sinus

Bed Wetting

Date Signed: _____________________________________________________________

Teeth, tonsils

Menstrual problems

Dentures

Hernia (rupture)

VII. PERMISSION TO LEAVE ACTIVITY

Bridge

Back, limbs, joints

My son has my permission to leave this Scouting activity in the custody of persons listed

here. My son will not be permitted to leave in the custody of any person not listed on this

Chest, lungs

Sleepwalking

form with prior permission.

Heart

Nervous condition

Name

Relationship

Other (explain)

Murmur

________________________________________________________________________

Rheumatic fever

________________________________________________________________________

If you answered “Yes” to any of the above, explain: ______________________________

________________________________________________________________________

Parent or Guardian:

_____________________________________________________

(Must sign if applicant is under 18)

LICENSED HEALTH-CARE PRACTITIONER

Date Signed: _____________________________________________________________

MUST COMPLETE REVERSE SIDE

YCC Rev. 2007

Camper Personal Health And Medical Record Form - Class 3

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