Adult Health History Record
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1Adult Health History Record
PLEASE TYPE OR CLEARLY PRINT ALL INFORMATION IN BLUE OR BLACK INK.
PART I: ADULT RECORD
Adult Name
Birth Date
Sex
Address/City/State/Zip
Family E-Mail Address
(For GSNC use only)
Cell Phone
Day Time Telephone
Evening Phone
(
)
(
)
(
)
HEALTH INFORMATION PRIVACY STATEMENT
The Adult Health History Record is for health care concerns at the specified event 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 history record will be retained by the council or GSUSA
until it is destroyed. All forms/records with noted treatment will be retained for seven years. Access to the information will be limited,
but copies may be requested from the council, by the participant or their legal representative.
I have read the above procedures for handling the health history record information and I agree to the release of any records
necessary for treatment, referral, billing or insurance purposes.
Adult Participant Signature:
Date:
PART II: HEALTH INSURANCE INFORMATION
Name of family DENTIST: _________________________________________________ Telephone: (
) ____________________________________
Name of family PHYSICIAN:_______________________________________________ Telephone: (
) ____________________________________
Family Medical/Hospital INSURANCE CARRIER:______________________________ POLICY/GROUP NUMBER: ______________________________
PART III: ALLERGIES/ILLNESSES/INJURIES
Allergic Reaction: (Check those that apply and specify nature of allergic reaction)
Check here for no known allergies
Animals ___________________
Hay Fever _________________
Medicines/Drugs ______________
Pollen __________________________
Food _____________________
Insect Stings _______________
Plants ______________________
Other (specify) ___________________
Chronic or Recurring Illnesses: (Check those that apply and give appropriate dates)
Arthritis ___________________
Asthma ___________________
Diabetes ____________________
Dizziness _______________________
Heart Defect/Disease ________
Bleeding/Clotting Disorders ___
Ear Infection _________________
Fainting ________________________
Hypertension _______________
Menstrual Problems _________
Musculoskeletal Disorder _______
Seizures ________________________
Date of last health examination: ________________________ Were any complicating medical problems noted in last health examination?
NO
YES
If YES, what? ________________________________________________________________________________________________________________
Other health conditions, chronic diseases, or injuries that might impact your participation: (Explain)_____________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
PART IV: MEDICATION
PART V: CONSENT TO TREAT
Are you taking any medications?
NO
YES
In the event of an emergency, every effort will be made to contact an
emergency contact. I hereby give authorization to Girl Scouts of Northern
If YES, list medication, reason, and possible side effects.
MEDICATION
POSSIBLE SIDE EFFECTS
California to seek treatment for myself by a licensed physician pursuant to
California Family Code Section 69I0 and California Civil Code 25.8. I know of
____________________________
__________________________
no reason(s), other than the information indicated on this form, why I should
____________________________
__________________________
not participate in prescribed activities.
____________________________
__________________________
____________________________
__________________________
____________________________
__________________________
:
Adult Participant Signature:
Date
PART VI: EMERGENCY CONTACT(S)
Name
Relationship
Cell Phone
Day Time Telephone
Evening Phone
1.
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(
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(
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2.
(
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(
)
(
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3.
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Updated_____________________________________ Date ________________
Please review this form annually. If there are no changes or just
minor adjustments, please mark those, then sign and date the form.
Updated_____________________________________ Date ________________
Updated_____________________________________ Date ________________
Forms Bank/Health Forms/HH_Adult_Health_History.doc 09/2008
Updated_____________________________________ Date ________________
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Parent category: Medical