Bsa Class 2 Medical Evaluation Form printable pdf download

BSA CLASS 2 MEDICAL EVALUATION

(Every 36 months)

A Class 2 record is required once every 36 months for all participants under 40 years of age. Includes any event that exceeds 72

consecutive hours where the level of activity is similar to that normally expended at home or at school, and where medical care is readily

available. Examples: resident camping, backpacking, tour camping, and hiking in relatively populated areas.

Note: Some states require an annual pre-camp medical evaluation. Your BSA local council service center can advise you about the

requirements in your state.

If your child has had a medical evaluation (physical examination) within the last 36 months, a copy of the results of this examination may be attached to

the health history [Class I] for all participants in a camping experience lasting longer than 72 consectuive hours (3 days and nights). If a copy is not

available, a physical examination (using below) must be scheduled by a licensed medical practitioner(*). A medical evaluation also is required if your

child is currently under medical care, takes a prescribed medication, requires a medically prescribed diet, has had an injury or illness during the past 6

months that limited activity for a week or more, has ever lost consciousness during physical activity, or suffered a concussion from a head injury.

Name _____________________________________________ Birth date ______________________

NOTE TO LICENSED MEDICAL PRACTITIONERS(*): The person being evaluated may be attending 1 or more weeks of camp, may be sleeping on the

ground, participating in strenuous activities such as hiking, boating, and vigorous group games. Please review the HEALTH HISTORY with the

participant for any interim changes. Explain any "abnormal" evaluations.

PHYSICAL EXAMINATION (To be filled out by a licensed medical practitioner)

Height ____________________ Weight ________________ BP __________ / __________ Pulse ____________________

Lab: Urinalysis (dipstick) ________________________ Albumin __________________ Sugar ____________________

VISION:

Normal ___________________________ Glasses ______________________ Contacts ____________________

HEARING:

Normal __________________ Abnormal __________________ Explain _________________________________

Check Box

Abn

Growth development

( ) ( )

Teeth

( ) ( )

Genitalia

( ) ( )

Cardiopulmonary system ( ) ( )

Skin

( ) ( )

Musculoskeletal

( ) ( )

HEENT

( ) ( )

Hernia

( ) ( )

Neurobehavioral

( ) ( )

Explain: ________________________________________________________________________________________________

Limitations

Activity restrictions ___________________________________________________________________________________

Diet restrictions _______________________________________________________________________________________

Physician

Name ___________________________________________ (M.D./D.O./D.C./P.A./R.N.P*.) _________________________

Signature _____________________________________________________________

Date __________________________

Address _______________________________________________________________ Phone __________________________

City, State, Zip _______________________________________________________________________________________

(*) Examinations conducted by licensed health care practitioners, other than physicians, will be recognized only in those states where

such practitioners may perform physical examinations for students enrolled in public school systems.

THIS FORM IS NOT INTENDED TO BE USED BY ADULTS OVER 40, BY HIGH ADVENTURE PARTICIPANTS (USE FORM NO.

34412), OR FOR NATIONAL JAMBOREE (USE FORM NSJ-34412).

BSA form 34414 Modified

Bsa Class 2 Medical Evaluation Form

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