Girl Health History Form - Girl Scouts Of Southern Alabama
Download a blank fillable Girl Health History Form - Girl Scouts Of Southern Alabama in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Girl Health History Form - Girl Scouts Of Southern Alabama with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Girl Health History Form
Contact Information
Girl Name
D.O.B.
Troop#
S.U.
Address
City/State/Zip
Home Phone #
Mother’s Name
Work #
Cell#
Father’s Name
Work #
Cell#
Emergency Contact
(not parent/guardian)
Name
Phone #
Relationship
Medical Information
Physician
Phone#
Medical Insurance
Subscriber
Policy/Group#
If Military Dependent, give location and I.D. number of child’s medical records
General Information: yes no
Allergies:
yes no
Special Needs:
yes no
Frequent headaches
Hay Fever
Disability
Corrective eye wear
Poison Oak, etc.
Hearing Impairment
Diabetes
Insect Stings
Visual Impairment
Sleepwalking
Asthma
Physical Impairment
Nosebleeds
Animals
Special Dietary Needs
Motion Sickness
Food
Other Special Needs
Convulsions
Drugs
Kidney
Other
Heart
Fainting
Epilepsy
If you checked yes to any of the boxes, please explain:
Date of last Tetanus shot:
Date of last TB skin test:
List any restrictions or special instructions:
List current medications (including over-the-counter):
All medications must be in their original container, accompanied by written instructions from the parent or physician, and given
to the troop leader.
This health history is complete and accurate. If circumstances chang e, I will notify the leader immediately.
The health of
the girl is primarily the responsibility of her parents or guardians. The Girl Scout organization strongly recommends annual
health examinations, dental check-ups, and immunizations against preventable diseases.
SIGNATURE of Parent/Guardian
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business