Bsa Personal Health And Medical Record Form Class 3 Page 2
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4BOY SCOUTS OF AMERICA
All Class 3 activities require a health examination within the past 12 months by a licensed health-care
practitioner.* This includes youth and adult members participating in high-adventure activities, athletic
competition, and world jamborees. Annually, this form is to be used by adults of 40 for all activities requiring a
physical examination and applies to all Wood Badge participants/staff regardless of age.
II. EMERGENCY MEDICAL INFORMATION
Has or is subject to (check and give details):
Allergy to medicine, food†, plant, animal, or insect toxin
Any condition that may require special care, medication, or diet
ADHD (Attention Deficit Hyperactive Disorder)
Asthma
Convulsions
Heart trouble
Contact lenses
Diabetes†
Fainting Spells
Bleeding disorders
Dentures
EXPLAIN _______________________________________________________________________
V. LICENSED HEALTH-CARE PRACTITIONER’S EVALUATION AND ADVICE
Approved for participation in:
Hiking and camping
Water activities
Competitive sports
All Activities
Specify exceptions ____________________________________________________________________________
Recommendations (explain any restrictions OR limitations): ___________________________________________
____________________________________________________________________________________________
Date ______________________________________
Signed _______________________________________________________________________________
*Licensed health-care practitioner
*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.
PLEASE TYPE OR PRINT
NAME_________________________________________________________ UNIT________________
NOTE: Keep original form for your personal record. Make reproductions for agency use. Be sure information and
signatures are legible on reproduced copies. This upper section may be reproduced and carried with you for
emergency identification and care.
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