Form 07-1273 - Girl Health Examination Record Form
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1Girl Scouts Central Maryland
4806 Seton Drive
Baltimore, MD 21215-3247
T 410 358.9711, 800 492.2521
F 410 358.9918
GIRL HEALTH EXAMINATION RECORD
This Side to be Filled in by the Parent and Reviewed with the Physician at the Time of Examination
_______________________________________________________________________________________________________
Name ( Last, First, Initial )
Parent / Guardian
Phone (
)
Address
City/ Town
State
Zip
Date of
Age
Sex
Birth
In Case of Emergency- Notify
Address
Phone (
)
Health History: (Check those that apply)
Diseases
Allergies
Chronic or Recurring Illness
Chicken Pox
Animals
Ear Infections
Measles
Food
Heart Defect/Disease
German Measles
Hay Fever
Seizures
Mumps
Insect Strings
Bleeding Disorders
Medicine/Drugs
Asthma
Plants
Hypertension
Pollen
Diabetes
Others
Musculoskeletal Disorder
Other (Specify)______________
Please describe condition and give dates:
Operations or serious injuries________________________________________________________________
Other diseases/disabilities ___________________________________________________________________
________________________________________________________________________________________
Comments where Applicable:
Fainting ________________________________ Sleep Disturbances_________________________________
Bed Wetting ____________________________ Menstrual Cramps_________________________________
Constipation ____________________________ Nosebleeds ______________________________________
Specific Activities to be Encouraged_____________________________ Restricted _____________________
Special medical or dietary regimen to be followed (specify) ________________________________________
This health history is correct and my daughter has permission to engage in all prescribed activities, except as noted by me
and the examining Physician.
Signature of Parent/Guardian_____________________________________Date____/___/____
This part to be filled in by physician after review of health history with parent/guardian
Health Examination: Date _____/_____/_____
Record of Immunization:
Height _________ Weight____________B.P________
Immunization
Year Primary
Year of last
Series Completed
Booster
Appearance - Nutrition _________________________
D.P.T
__________
_________
Diphtheria
_________
Without Glasses
With Glasses
Pertussis (Whooping Cough)
_________
Eyes R 20/ ___ L 20/___
R 20/___ L 20/___
Tetanus
_________
Ears _______________ Hearing R ________ L _____________
Td
__________
_________
Satisfactory
(√ )
Oral Polio
__________
_________
Code:
Not Satisfactory (x )
Measles
__________
_________
Not Examined
(o )
Mumps
__________
_________
Rubella
__________
_________
Nose_______________
Throat______________
Hbpv
__________
_________
Teeth ______________
Heart ______________
Tuberculin Test Type Yr last given ______ Result ________
Lungs ______________
Abdomen ___________
Other _________
__________
_________
Genitalia ____________
Hernia _____________
This person is in satisfactory condition and may engage
Skin ________________
Musculoskeletal ______
in all usual activities except as noted.
General physical and emotional status _____________
Licensed physician's name___________________________
Urinalysis* ___________
HBG*______________
Licensed physician's Signature _______________________
Physician's comments and recommendation: ________________
Address__________________________________________
____________________________________________________
City _________________ State___________ Zip ________
____________________________________________________
Phone __________________________________________
____________________________________________________
Date: ___________________
*Not required for every health examination. Cadette/Senior/
Ambassador Girl Scout should have this test if she has not had
it since puberty.
07-1273
07/03
Reviewed 06/2010
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