Girl Or Adult Health History Record - Girl Scouts Of Western Washington
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2Girl or Adult Health History Record
To be completed and signed by parent/guardian of girls or by adult members for themselves.
Name: __________________________ Date of Birth:___________ Age:___________ ☐ Girl ☐ Adult
Address: __________________________________________________________________________
Parent/Guardian if Under 18:____________________________ Phone:_________________________
Address (if different than girl’s address): __________________________________________________
Doctor’s Name:______________________________________ Phone:_________________________
Emergency Contact:___________________________________ Phone:________________________
Health Conditions: Past and Present
[Check all that apply]
Arthritis
Hernia
☐
☐
Asthma
Hypertension/High Blood Pressure
☐
☐
Bedwetting
Intestinal Disorders/Constipation
☐
☐
Bleeding disorder
Kidney/bladder illness
☐
☐
Convulsions/Epilepsy/Seizures
Menstrual cramps
☐
☐
Diabetes
Musculoskeletal Disorders
☐
☐
Diseases of the Ear or Ear Infections
Mental/psychological disorder
☐
☐
Eating Disorders (Anorexia, Bulimia, etc.)
Nosebleeds
☐
☐
Eyesight Impairment
Sinusitis (Sinus Infections)
☐
☐
Fainting/dizzy spells
Sleep Disturbances
☐
☐
Headaches/Migraines
Sleep Impairment
☐
☐
Hearing Impairment
Had surgery or hospitalized in the last 5 years
☐
☐
Heart Defects/Disease
Currently under doctor or psychologist’s care
☐
☐
Other:
☐
Date of last health examination:
Were any complicating medical problems noted in the
last health exam? ☐ Yes ☐ No
Please explain in detail any items checked above:
Since last health exam, has participant had:
A serious injury requiring medical attention?
Treatment in a hospital or emergency room?
☐ Yes ☐ No
☐ Yes ☐ No
A surgical procedure or fracture?
Any exposure to a contagious disease?
☐ Yes ☐ No
☐ Yes ☐ No
Does your child have any restrictions concerning physical activities? ☐ Yes ☐ No Explain:
Allergies
Allergies
Reaction/Severity
Treatment
Date of Last Reaction
Does your child suffer from Anaphylaxis?* ☐ Yes ☐ No
*A severe allergic reaction marked by swelling of the throat or tongue, hives, and trouble breathing.
Does she carry an Epipen? ☐ Yes ☐ No
Does she carry an inhaler? ☐ Yes ☐ No
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