Personal Health And Medical Record Form printable pdf download

PERSONAL HEALTH AND MEDICAL RECORD

CLASS 1 AND CLASS 2

Height __________ Weight __________ Eye color __________ Hair color __________

CLASS 1 PERSONAL HEALTH AND MEDICAL HISTORY

(To be filled out annually by all participants)

To be filled out by parent, guardian, or adult participant. Please print in ink.

IDENTIFICATION

Name ____________________________________________________ Date of birth_______________ Age_______ Sex_______

Name of parent or guardian _____________________________________________________ Telephone__________________

Home address __________________________________ City_______________________ State__________ Zip_____________

Business address ______________________________ City_______________________ State__________ Zip_____________

If person named above is not available in the event of an emergency, notify

Name _______________________________________ Relationship____________________ Telephone____________________

Name of personal physician ____________________________________________________ Telephone____________________

Personal health/accident insurance carrier ________________________________________ Policy No.____________________

Check all items that apply, past or present, to your health history. Explain any “Yes” answers.

ALLERGIES: Food, medicines, insects, plants Yes

Explain: ____________________________________________

■

GENERAL INFORMATION:

Yes No

Yes

ADHD (Attention-Deficit

Hyperactivity Disorder)

Convulsions/seizures

Hemophilia

■

Asthma

Diabetes

High blood pressure

■

Cancer/leukemia

Heart trouble

Kidney disease

■

Explain: _______________________________________________________________________________________________

Please list ALL medications taken in the 30 days prior to arrival at the Scouting activity where this form is to be used: _________

______________________________________________________________________________________________________

List any medications to be taken at camp, including drug, dosage, route (oral, injection, etc.), and frequency: ______________

______________________________________________________________________________________________________

List any physical or behavioral conditions that may affect or limit full participation in swimming, backpacking, hiking long distances,

or playing strenuous physical games: ________________________________________________________________________

List equipment needed such as wheelchair, braces, glasses, contact lenses, etc.: ______________________________________

Immunizations: (Give date of last inoculation.)

Tetanus toxoid ____________________

Measles ___________________

Polio _____________________

OR DPT

____________________

OR MMR ___________________

_________________________

Hepatitis A

____________________

Varicella ___________________

OR Chicken pox ____________

Hepatitis B

____________________

I give permission for full participation in BSA programs, subject to limitations noted herein.

In case of emergency, I understand every effort will be made to contact me (if participant is an adult, my spouse or next of

kin). In the event I cannot be reached, I hereby give my permission to the licensed health-care practitioner selected by the

adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication

for my child (or for me, if participant is an adult).

Date______________ Signature of parent/guardian or adult __________________________________________________

Date updated______________ Signature of parent/guardian or adult __________________________________________

Date updated______________ Signature of parent/guardian or adult ___________________________________________

Some hospitals require the parent/guardian signature to be notarized. Check with your BSA local council.

Personal Health And Medical Record Form

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