Girl Scouts Of Gulfcoast Florida Girl Health Examination Record Form printable pdf download

Girl ScoutS of GulfcoaSt florida, inc. Girl HealtH examination record

this form must be completed by a physician (md or do), Physician’s assistant (Pa) or nurse Practitioner (arnP).

Name _____________________________________________________________________________________ Date ______/______/____________

immunization

year primary series

year of last booster

Height ______________ Weight _______________ B.P . ______________

completed

DtaP

Appearance-Nutrition ___________________________________________

Diphtheria

Pertussis (Whooping Cough)

Eyes without glasses:

right 20/ ____________ left 20/ _____________

tetanus (within last 10 years)

Eyes with glasses:

right 20/ ____________ left 20/ _____________

Oral Polio/IPV

Ears _____________________ Hearing: right _________ left __________

measles

Code: S = satisfactory | nS = not satisfactory | ne = not examined

mumps

Rubella

_________ Nose

_________ throat

Hib

_________ teeth

_________ Heart

Hepatitis B

_________ Lungs

_________ Abdomen

tuberculin test

last year given:

result:

_________ Genitalia

_________ Hernia

_________ skin

_________ musculoskeletal

_________ urinalysis *

_________HGB *

typhoid and Paratyphoid

Other notes ____________________________________________________

Cholera

_______________________________________________________________

Yellow Fever

typhus

_______________________________________________________________

Rocky mountain spotted Fever

Physician’s comments and recommendations. Give details or

indicate care instructions for significant illness, and any restricted

activities.

this person is in satisfactory condition and may engage in all usual

_______________________________________________________________

activities except as noted.

_______________________________________________________________

Licensed medical

_______________________________________________________________

provider’s signature__________________________________________________

_______________________________________________________________

Address ____________________________________________________________

_______________________________________________________________

City _________________________________ state ________ Zip _____________

* Not required for every health exam. Girls ages 11-18 should have this test if

Phone (______) _________________________ Date ______/______/__________

she has not had it since entering puberty.

PleaSe liSt current medicationS beinG taken on SeParate PaPer and attacH.

include doSaGe and any Potential Harmful interactionS (food, medicationS, environmental).

HealtH information Privacy Statement

the Girl Health Examination Record is for health care concerns at the specified event/camps 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 until it is destroyed. All forms/records with noted treatment will be retained for seven years

past the age of maturity of the participant. Access to the information will be limited, but copies my 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.

signature of parent/guardian _____________________________________________________

Date ______/______/____________

C:ShelfForms/2011Forms/HealthExaminationRecord ~ Rev. 2/11