Girl Or Adult Health History Record - Girl Scouts Of Western Washington Page 2
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1
2Record of Immunization [Must be completed in detail]
Date
Year of
Date
Year of
Immunization
Series
Last
Immunization
Series
Last
Completed
Booster
Completed
Booster
Hepatitis B
Hepatitis A
Diphtheria, Tetanus,
Inactivated Poliovirus (IPV)
Pertussis (DTap/Tdap)
Measles, Mumps, Rubella
Influenza
MMR)
Rotavirus (RV)
Varicella
Haemophilus influenzae
Meningococcal (MCV)
type b (Hib)
Pneumococcal (PCV)
Human Papillomavirus (HPV)
Tuberulin Test:
Result:
Date:
Other:
Medications and Dietary Restrictions
List any medications including dosage schedule and specific instructions for use. ALL prescriptions must be in the
original container with appropriate label.
Medication
Purpose
Dosage
Specific Instructions
Over-the-Counter Medications:
Parent/Guardian of Minors: My daughter has permission to take the following medications in case of
accident/injury:
Tylenol/Acetaminophen
Pepto Bismol
☐
☐
Aspirin (fever reducer)
Imodium (anti-diarrhea)
☐
☐
Ibuprofen (pain/swelling)
Dramamine (motion sickness prevention)
☐
☐
Benadryl/Antihistamine
Tums/antacid
☐
☐
Robitussin/expectorant
Sudafed/decongestant
☐
☐
Skin Ointments (in case of rash, antibacterial, athlete’s foot, etc.)
☐
Other:
Special consideration or notes:
I have reviewed the Girl Scouts of Western Washington policy on administering medication to a minor
and submitted the appropriate permission forms to the adult in charge.
☐ Yes ☐ No ☐ N/A - My child is not currently taking any prescribed or OTC medications.
My child has the following dietary restrictions:
For Parents/Guardians: I know of no reason (s), other than the information indicated on this form, why
my daughter should not participate in prescribed activities except as noted.
Signature of parent/guardian: __________________________________ Date:________________
For adults: This health history is correct and I am able to participate in all prescribed activities except
as noted.
Signature of adult: ___________________________________________ Date: ________________
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