Fillable Bsa Medical Form Part C - 2014 printable pdf download

Part C:

Pre-Participation Physical

This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants.

High-adventure base participants:

Full name:

________________________________________

Expedition/crew No.: _______________________________

or staff position: ___________________________________

DOB:

________________________________________

You are being asked to certify that this individual has no contraindication for participation inside a

Scouting experience. For individuals who will be attending a high-adventure program, including one

of the national high-adventure bases, please refer to the supplemental information on the following

pages or the form provided by your patient.

Examiner: Please fill in the following information:

Yes

Explain

Medical restrictions to participate

Yes

Allergies or Reactions

Explain

Yes

Allergies or Reactions

Explain

Medication

Plants

Food

Insect bites/stings

Height (inches):__________________ Weight (lbs.):__________________ BMI:__________________ Blood Pressure:__________________/__________________ Pulse:__________________

Examiner’s Certification

Normal

Abnormal

Explain Abnormalities

I certify that I have reviewed the health history and examined this person and find

no contraindications for participation in a Scouting experience. This participant

Eyes

(with noted restrictions):

True

False

Explain

Ears/nose/

throat

Meets height/weight requirements.

Does not have uncontrolled heart disease, asthma, or hypertension.

Lungs

Has not had an orthopedic injury, musculoskeletal problems, or

orthopedic surgery in the last six months or possesses a letter of

clearance from his or her orthopedic surgeon or treating physician.

Heart

Has no uncontrolled psychiatric disorders.

Has had no seizures in the last year.

Abdomen

Does not have poorly controlled diabetes.

If less than 18 years of age and planning to scuba dive, does not have

diabetes, asthma, or seizures.

Genitalia/hernia

For high-adventure participants, I have reviewed with them the

important supplemental risk advisory provided.

Musculoskeletal

Examiner’s Signature: ___________________________________ Date: _______________

Provider printed name: ________________________________________________________

Neurological

Address: ______________________________________________________________________

City: _____________________________________ State: ____________ ZIP code: _________

Other

Office phone: _________________________________________________

Height/Weight Restrictions

If you exceed the maximum weight for height as explained in the following chart and your planned high-adventure activity will take you more than 30 minutes away from an

emergency vehicle/accessible roadway, you may not be allowed to participate.

Maximum weight for height:

Height (inches)

Max. Weight

Height (inches)

Max. Weight

Height (inches)

Max. Weight

Height (inches)

Max. Weight

166

195