Adult Health Examination Record
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2Girl Scouts of Citrus Council, Inc.
341 N. Mills Ave., Orlando, FL 32803, (407) 896-4475 or (800) 367-3906 / FAX (407) 894-0966
ADULT HEALTH EXAMINATION RECORD
This part to be filled in by adult and reviewed with physician at the time of examination
Name (Last, First, Initial)
Sex
Birth
Address
City or Town
State
Zip
Phone
(
)
In Emergency Notify
Address
Relationship
Phone
(
)
Insurance Information, please complete the following:
Carrier
ID Number
Group Number
Member Services Phone Number
Address
Health History: (Check if you have had any of the following)
Eyesight Impairment
Disease of Kidneys
Arthritis
Disease of Ears
Hearing Impairment
Heart Disease
Diabetes
Intestinal Disorders
Speech Impairment
Rheumatic Fever
Tuberculosis
Chicken Pox
Disorders of Nervous
Abnormal Blood Pressure
Hernia
Measles
System
Mental or Emotional Disorders
Asthma or Hay Fever
Mumps
Sinusitis
Severe Menstrual Pain
Other serious allergies
German Measles
Lyme Disease
Other
Have you been hospitalized in the last five years?
Yes
No
Are you taking any medication?
Yes
No
Explain:.
If you have checked or answered yes to any of the above, give nature, dates, period of any disability and results:
PLEASE LIST CURRENT MEDICATIONS BEING TAKEN BELOW — INCLUDE DOSAGE AND ANY POTENTIAL
HARMFUL INTERACTIONS (e.g. food, medications, environmental)
I certify that to the best of my knowledge this health history is complete and accurate. I am in good health and able
to participate in this event/assignment.
Signature of Applicant:
Date:
HEALTH INFORMATION PRIVACY STATEMENT
The Adult Health Examination Record is for health care concerns at the specified event only. All records will be handled by
staff/volunteers whose job includes processing or using this information for the benefit of the participant. All medical records will be
held in limited access by the health care supervisor of the specific event. Minimal necessary information may be shared with event
staff/volunteers in order to provide adequate participant safety and health care. The health form will be retained by the sponsoring
council or GSUSA until it is destroyed. All forms/records with noted treatment will be retained for seven years. Access to the
information will be limited, but copies may be requested from the event sponsor, by the participant or their legal representative.
I have read the above procedures for handling the health form information and I agree to the release of any records
necessary for treatment, referral, billing or insurance purposes.
PARTICIPANT SIGNATURE:
Date:
Health Exam - Adult_v1
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