Girl Scout Medical Information - Girl Scouts Of San Jacinto Council
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1
2GIRL SCOUT MEDICAL INFORMATION
Girl Scouts of San Jacinto Council
THIS FORM MAY BE PHOTOCOPIED WHEN COMPLETED. PRINT CLEARLY, USE BLACK INK.
Girl's Name
Troop/Group #
Phone
Home Address
City
State
ZIP
Date of Birth
Date of last Health Exam
Girl's Physician/Clinic
Phone
Parent/Legal Guardian
Phone
Cell Phone
HOSPITAL INSURANCE INFORMATION Attach photocopy of insurance card.
Name of Carrier
Policy #
Insured's name
Member ID#
Company name if insured through employer
Phone:
Others who could be contacted to authorize treatments:
Name
Day
Relationship
Evn
Day
Name
Relationship
Evn
Allergies
PART I
(Check those that apply. Specify cause and nature of reactions - e.g. penicillin causes hives.)
__Animals
__Plants
__Food
__ Medicine/Drugs
__Hayfever
__Pollen
__Insect Sting
__Other:
In case of an allergic reaction, respond by
Health Conditions
PART II
(Check those that apply.)
Chronic or reoccurring illness:
__Asthma
__Musculoskeletal Disorders
__Kidney Disease
__Diabetes
__Heart Disease/Defects
__Hypertension
__Seizures
__Bleeding/Clotting Disorder
__Ear Infection
__Other:
I
L
Y
: (A
YES
NO)
N THE
AST
EAR
NSWER
OR
Complicating medical problems/operations?
Serious injury/illness requiring medical care? ____________
Explain:
S
I
/ ONGOING TREATMENTS:
PECIFIC
NSTRUCTIONS
Other Health Conditions
PART III
(Check those that apply.)
__Sleep disturbances
__Motion sickness
__Constipation/diarrhea
__Bedwetting
__Hepatitis A / B / C
__Menstrual complications
__Sickle cell trait or disease
__ADHD / ADD
__Emotional disturbances
__Hearing impairment
__Special dietary regiment
__Fainting
__Physical disabilities
__Frequent headaches
__Wears contact lenses/glasses
__Nosebleeds
__Orthodontic appliances
__Eating disorders
__Other specify
_____________________________________________________________________________________
Please explain. Indicate any information useful to the adult in charge in relation to any of the above health conditions.
Indicate any activity to be encouraged or restricted ________________________________________________________________
Dietary Needs / Restrictions: _________________________________________________________________________________
GIRL SCOUT INSURANCE CARRIER: MUTUAL OF OMAHA
For confirmation, contact Girl Scouts of San Jacinto Council 713-292-0300 or 1-800-392-4340
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