Form Prog076.1 - Girl/adult Health History Form
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2Girl Scouts of Silver Sage
GIRL/ADULT
1410 Etheridge Lane
Boise, ID 83704
HEALTH HISTORY FORM
(208) 377-2011 or (800) 846-0079
FAX (208) 377-0504
Girl Member
Please Print Clearly in Ink
Troop #__________________
Adult Member
Service Unit #____________
Contact Information
First Name
Middle Name
Last Name
_____________________________________________________________________________________________________________________
Mailing/Physical Address
City
State
ZIP
_____________________________________________________________________________________________________________________
Home Phone
Cell Phone
E-mail Address
Parent/Guardian #1 (complete for girl only)
First Name
Middle Name
Last Name
_____________________________________________________________________________________________________________________
Address (if different from above)
_____________________________________________________________________________________________________________________
Home Phone
Cell Phone
E-mail Address
Parent/Guardian #2 (complete for girl only)
First Name
Middle Name
Last Name
_____________________________________________________________________________________________________________________
Address (if different from above)
_____________________________________________________________________________________________________________________
Home Phone
Cell Phone
E-mail Address
Emergency Contact (non parent)
First Name
Middle Name
Last Name
____________________________________________________________________________________________________________________
Relationship
Home Phone
Cell Phone
Health Information
Name of Family Physician
Phone
____________________________________________________________________________________________________________________
Family Medical/Hospital Insurance Carrier
Policy or Group #
____________________________________________________________________________________________________________________
Family Dental Insurance Carrier
Policy or Group #
____________________________________________________________________________________________________________________
Age _________
Immunizations Up to Date ____yes ____no ___N/A
Date of last Tetanus shot
/
/
____________________________________________________________________________________________________________________
Date of last health examination
/
/
Where there any medical problems at the time?
____________________________________________________________________________________________________________________
Has participant had any recent injuries or surgery? ___yes ___no If yes, please explain and specify date:
____________________________________________________________________________________________________________________
Does participant take any prescribed medications on a regular basis? ___yes ___no
If yes, please state medication and reason
____________________________________________________________________________________________________________________
Is participant restricted or limited from participating in any physical activity ___yes ___no
If yes, please explain
____________________________________________________________________________________________________________________
Participant has the following health conditions/allergies (food and medications)
__ADHD __Asthma __ Diabetes __Headaches __Seizures __Other___________________________________________________________
Allergies (specify)
(over)
PROG076.1 (8/2012)
Troop Leader—Please retain for your records
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Parent category: Business