Camper Personal Health And Medical Record Form - Class 3 Page 2
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2PERSONAL HEALTH AND MEDICAL RECORD FORM - Class 3
BOY SCOUTS OF AMERICA
PAGE 2 of 2
NOTE TO LICENSED HEALTH-CARE PRACTITIONER: The applicant will be participating in a strenu-
IX. MEDICAL HISTORY
ous activity that will include one or more of the following conditions: athletic competition, adventure
• Please insist that the applicant furnish a complete medical history (Part IV) before exam
challenge or wilderness expedition (afoot or afloat) that may include high altitude, extreme weather
• Review immunizations. For applicants under 18, tetanus, diphtheria toxoids, measles,
conditions, cold water, exposure, fatigue, and/or remote conditions where readily available medical care
cannot be assured.
mumps and rubella vaccines and trivalent oral polio vaccine are required. Youth and
adults are required to have a tetanus booster within 10 years.
ALL SECTIONS OF THIS FORM MUST BE COMPLETED. Attachments may be included to aid the
health officer in better serving your patient, however it is necessary that this form be completed in full
Date: ____________________________________ VISION
HEARING
and signed by the licensed health-care practitioner to comply with the health and safety requirements of
the Boy Scouts of America.
Height: _______________ Weight: _____________ Normal ________ Normal _________
VIII. LICENSED HEALTH-CARE PRACTITIONER’S EVALUATION
Blood Pressure: _____________ / _____________ Glasses ________ Abnormal________
This applicant is approved for participation in:
Pulse: ____________________________________ Contacts _______
Hiking and Camping
Competitive Sports
Check if normal, circle if abnormal and give details below:
Water Activities
All Activities
Growth, development
Respiratory
Neuropsyciatric
Specify Exceptions: _____________________________________________________
Teeth, tonsils
Skeletomuscular
Eyes, ears, nose
Genitourinary
Head, Neck, Thyroid
Abdomen, hernia, rings
________________________________________________________________________
Skin, glands, hair
Cardiovascular
Other (specify)
YYCC
Recommendations (explain any restrictions or limitations):
Comments: ______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Immunizations have been reviewed:
X
________________________________________________________________________
Signed:
_______________________________________________________________
________________________________________________________________________
M.D. / D.O. / D.C. / P.A. / R.N.P. (circle one)*
X
Print Name:
___________________________________ Phone: _________________
INTERVAL RECORD
DATE, TIME, PLACE
FINDINGS, DIAGNOSIS, TREATMENT, ETC
BY
Date Signed: _____________________________________________________________
*Examinations conducted by licensed health-care practitioners other than physicians will be recognized
for BSA purposes in those states where such practitioners may perform physical examinations within
their legally prescribed scope of practice.
X. IMMUNIZATIONS
2 doses of MMR are required unless applicant was born before 1957 or is entering the
6th grade. Hepatitis B is required if the applicant was born after 1/1/92. A minimum of 4
DPT/DT/TD are required, the last one within the last 10 years. The last polio dose must
be after age 4. If applicant has had the disease, please mark with a “D” and the year.
MMR
POLIO
HEPATITIS B
DPT/DT/TD
OTHER
XI. ORDERS TO ADMINISTER PRESCRIPTION MEDICATION
This section must be completed by the licensed health-care practitioner (authorized to
prescribe medication) if prescription medication is to be administered during BSA activi-
ties. NOTE: During summer camp, only the Camp Health Officer is authorized to store
and administer prescription medication, except as noted below.
Medication: _____________________________________________________________
Prescription Number: _______________________________________________________
Dosage: ____________________________ Frequency: ___________________________
Condition requiring medication: _______________________________________________
Common side effects: ______________________________________________________
Medication that may be self-administered:
Asthma Inhaler
Epi Pen
Other: ___________________________________
PARENT OR GUARDIAN MUST
Signature of Licensed
X
Health-Care Practitioner:
_________________________________ Date: ___________
COMPLETE REVERSE SIDE
YCC Rev. 2007
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