Girl/adult Health History Form
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1Girl/Adult Health History
Girl
Adult
Date completed: __________/__________/__________
Name (last, first, middle initial)
Parent/Guardian
(Area code) Phone
Address
City/Town
State
Zip Code
Date of Birth
Age
Sex
In Emergency Notify
Address
(Area Code) Phone
HEALTH HISTORY: (check those that apply)
Diseases
Allergies
Chronic or Recurring Illness
__Chicken Pox
__Animals
__Plants
__Ear Infections
__Hypertension
__Measles
__Food
__Pollen
__Heart Defect/Disease
__Diabetes
__German Measles
__Hay Fever
__Other
__Seizure Disorder
__Muscoloskeletal Disorders
__Mumps
__Insect Bites
__Medicine/Drugs
__Asthma
__Other (specify)
Operations or serious injuries
Hospitalizations
Other diseases/disabilities
Comments where applicable:
Fainting
Sleep disturbances
Bed wetting
Menstrual cramps
Constipation
Nosebleeds
Emotional disturbances
Other
Specific activities to be encouraged
restricted
Special medical or dietary regimen to be followed (specify)
Can be given Tylenol:
yes
no
Name of Physician:
Phone:
This health history is complete and accurate. My daughter has permission to engage in all prescribed activities except as noted
by me and/or the examining physician.
(X)
(Signature of parent or guardian holding legal custody)
(Date)
EMERGENCY RELEASE STATEMENTS
FOR GIRLS:
In an emergency, when the undersigned or other emergency contact person cannot be reached, I give permission
for the person in authority to take any emergency measure deemed appropriate. The parent/guardian holding legal custody will
be notified as soon as possible.
(X)
(Signature of parent or guardian holding legal custody)
(Date)
FOR ADULTS:
In an emergency, should it happen that I am incapable or that the person named emergency contact can not be
reached promptly, I give my permission for the person in authority to take any emergency measure deemed appropriate. My
emergency contact will be notified as soon as possible
(X)
(Signature of adult filling out this form)
(Date)
THIS FORM MUST GO WITH THE PERSON NEEDING ANY EMERGENCY TREATMENT.
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