Personal Health And Medical Record Form
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1
2PERSONAL HEALTH AND MEDICAL RECORD FORM—Class 3
BOY SCOUTS OF AMERICA
PLEASE TYPE
All Class 3 activities require a health examination within the past 12 months by a
OR PRINT.
licensed health-care practitioner.* This includes youth and adult members participating
I. IDENTIFICATION
Age_____ Sex_____
Date of Birth*
in high-adventure activities, athletic competition, and world jamborees. Annually, this
form is to be used by adults over 40 for all activities requiring a physical examination
Name___________________________________________________
Last name
First name
Initial
Mo.
Day
Year
and applies to all Wood Badge participants/staff regardless of age.
Address ______________________________________________________________________
II. EMERGENCY MEDICAL INFORMATION
City & State ______________________________________________Zip____________________
Health/Accident
Has or is subject to (check and give details):
insurance________________________________Policy no.______________
Allergy to a medicine, food†, plant, animal, or insect toxin
Any condition that may require special care, medication, or diet
IN AN EMERGENCY NOTIFY:
ADHD (Attention Deficit Hyperactive Disorder)
Name ___________________________________________Relationship __________________
Asthma
Convulsions
Heart trouble
Contact lenses
Address ____________________________
Home phone
Diabetes†
Fainting spells
Bleeding disorders
Dentures
City &
Business
State _______________________________
phone
EXPLAIN______________________________________________________
Personal
Physician ___________________________
Phone
III. PARENTAL STATEMENT
IV. IMMUNIZATIONS
V. LICENSED HEALTH-CARE PRACTITIONER’S EVALUATION AND ADVICE
Has it ever been necessary to restrict applicant’s activities for med-
If disease, put “D” and
Approved for participation in:
ical reasons?
No
Yes Does applicant take medicine regu-
year.
Last year
larly or have special care?
No
Yes If yes, explain.
Hiking and camping
Water activities
given
______________________________________________________
Competitive sports
All activities
Tetanus
__________
To the best of my knowledge, the information in sections I, II, III, IV,
Specify exceptions _____________________________________________________
Diphtheria
__________
and VI is accurate and complete. I request a licensed health-care
Recommendations (explain any restrictions OR limitations): _____________________
Pertussis
__________
practitioner to examine applicant, to give needed immunization, and
to furnish requested information to other agencies as needed. I give
Measles
__________
____________________________________________________________________
my permission for full participation in BSA programs, subject to limita-
Mumps
__________
____________________________________________________________________
tions noted herein. In the event of illness or accident in the course of
such activity, I request that measures be instituted without delay as
Rubella
__________
Date____________________
judgment of medical personnel dictates.
Polio
__________
Signed _______________________________________________________________
Parent or guardian________________________________________
*Licensed health-care practitioner
Chicken Pox __________
(Must sign if applicant is 18 or younger)
*Examinations conducted by licensed health-care practitioners other than physicians
Religious preference
Applicant’s signature ______________________________________
will be recognized for BSA purposes in those states where such practitioners may
perform physical examinations within their legally prescribed scope of practice.
Date signed _____________________________________________
VII. HEALTH EXAMINATION
VI. MEDICAL HISTORY
Licensed Health-Care Practitioner:
Parent (or applicant if 18 or older): Fill in sections I, II, III, IV, and VI before seeing a licensed health-care
practitioner. Check immunizations to be given at this time. Be sure to include any emergency information and
restrictions or special care that should be observed. Especially be sure to record any injuries, illnesses,
The applicant will be participating in a strenuous activity that will include one or more of the following
surgery, or significant changes in condition of health of applicant since last complete examination.
conditions: athletic competition, adventure challenge or wilderness expedition (afoot or afloat) that
may include high altitude, extreme weather conditions, cold water, exposure, fatigue, and/or remote
• Date of most recent complete physical examination (month and year) ______________________ 19_____
conditions where readily available medical care cannot be assured.
• Are you aware of any current health problems?
No
Yes
• Now under medical care or taking medicines?
No
Yes
• Has there been any surgery, injury, illness, allergy, or change
• Please insist applicant furnish complete medical history (VI) before exam.
• Review immunizations; for youth (18 or younger) tetanus and diphtheria toxoids, measles, mumps, and
in health status since last complete physical examination?
No
Yes
rubella vaccines, and trivalent oral polio vaccine are required; youths and adults must have had tetanus
Give dates and full details below for any “yes” answers.
booster within 10 years. A measles booster is recommended at age 12.
IS THERE DISEASE OF
• After completing section VII, summarize any restrictions and/or recommendations in sections II and V,
(OR PAST OR PRESENT
above, and sign.
HISTORY OF):
No
Yes
Year
Details/Medicines
VISION:
HEARING:
Date _______________________________
Normal______________ Normal _______________
Serious illness
________
Ht. _______________ Wt. _____________
Glasses _____________ Abnormal _____________
Serious injury
________
B.P.________ / _________Pulse _______
Contacts ____________
Deformity
________
Surgery
________
Check box if normal; circle if abnormal and give details below:
Skin, glands
________
Growth, development
Teeth, tonsils
Genitourinary
Ears, eyes
________
Skin, glands, hair
Respiratory
Skeletomuscular
Nose, sinus
________
Head, neck, thyroid
Cardiovascular
Neuropsychiatric
Teeth, tonsils
________
Eyes, ears, nose
Abdomen, hernia, rings
Other (specify)
Dentures
________
COMMENTS ________________________________________________________________________
Bridge
________
__________________________________________________________________________________
Chest, lungs
________
Heart
________
__________________________________________________________________________________
Murmur
________
__________________________________________________________________________________
Rheumatic fever
________
Stomach, bowels
________
__________________________________________________________________________________
Appendicitis
________
__________________________________________________________________________________
Kidneys or urine
________
Albumin
________
Sugar
________
FOR THOSE ATTENDING PHILMONT OR NATIONAL HIGH-ADVENTURE BASES:
Infection
________
Please list ALL medications taken
* The minimum age for all participants is 13 by January 1 of the year of participation, or have completed
Bed-wetting
________
in the 30 days prior to arrival at the
the seventh grade. No exceptions.
Menstrual problems
________
Scouting activity where this form is
† Trail food is by necessity a high-carbohydrate, high-calorie diet. It is high in wheat, milk products, sugar,
to be used:
Hernia (rupture)
________
corn syrup, and artificial coloring/flavoring. Dinner meals contain meat. If these food products cause a
Back, limbs, joints
________
problem in your diet, you need to bring appropriate substitutions with you and so advise base personnel.
Sleepwalking
________
Note: Licensed health-care practitioners representing high-adventure bases reserve the right to deny
Nervous condition
________
access to the trails or other program activity on the basis of a medical evaluation performed at the
Other (explain)
________
base after arrival.
No. 34412A
1999 Printing
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