Health History Form for Girls and Adults

 

This form is carried on outings.  Please fill out completely.  This information will be used by a health care provider when medical care is needed.  This form must accompany all individual registrations for Cadette and Senior Girl Scouts.  (This form is to be filled out by parents/guardians of minors or by adult members themselves.)

Participant’s Name ______________________________________________________  Name used ___________________
                                                             Last                                 First                                    Initial
Parent/Guardian (or spouse if adult) ______________________________________________________________________

Address __________________________________________________________ Home Phone (____)__________________
                                   Street & Number                                City                         State                Zip                                      Area                  Number

                                   Business Phone (Mother) (____)__________________ Cell Phone ___________________________
                                   Business Phone (Father)    (____)__________________ Pager _______________________________

Troop # __________       Program in fall:   ____ Daisy   ____Br.   ____ Jr.   ____ Cad.   ____ Sr.   ____ Non-Girl Scout
Age _______ Birth date: (Month, date & year) _____________  Participant’s Social Security # ____________________

Emergency Contact (other than parents):  Name ________________________________________________________________
Address _______________________________________________________________  Phone (____)__________________

                                                   Street & Number                                  City                     State                Zip                        Area                  Number
Cell Phone _____________________  Business Phone ___________________  Relation to participant ________________

Current prescription medications _________________________________________________________________

 

Current over-the-counter medications (send with instructions) ____________________________________________________

 

All medications:
        Ÿ Must have parent permission, signed and dated, with specific dosage instructions.
        Ÿ Must be in original container.
        Ÿ Must be turned in to Adult First-Aider.

If participants must keep any medications with them, notify Adult First-Aider in writing.

Other diseases ________________________________________________________________________________

Name of dentist/orthodontist ___________________________________________  Phone ___________________________

Name of family physician _____________________________________________  Phone ___________________________

 

Do you carry family medical/hospital insurance?     q Yes    q No

If so, indicate: Carrier __________________________________________  Policy or Group # ________________________

Name of person with insurance ________________________________________________

Suggestions on health related information for Girl Scout program activities. _______________________________________

____________________________________________________________________________________________________

 

Recommendations and Restrictions

 

Any treatment to be continued ___________________________________________________________________

____________________________________________________________________________________________
Any allergies (food, drugs, plants, insects, etc.) ______________________________________________________
____________________________________________________________________________________________
Activities  to be encouraged or limited _____________________________________________________________
____________________________________________________________________________________________
Additional health information ____________________________________________________________________
____________________________________________________________________________________________

Chronic or recurring illness or medical condition ____________________________________________________________

____________________________________________________________________________________________________

Immunization History

         Date           Vaccine                                                                       Date           Vaccine
    ________       DPT                                                                        ________       Rubella
    ________       TD (tetanus/diphtheria)                                             ________       Hemophilus Influenza B
    ________       Tetanus                                                                    ________       Hepatitis B
    ________       Polio                                                                        ________       Date of last TB Mantox test
    ________       Measles (hard or red measles or rubella)                                         Result __________________

Emergency Medical Information and Health History

Has, has had, or is subject to: (Check and give details)
q Allergies: Foods, medicines, insects, plants, pollen, animals.  Explain: _________________________________
q Asthma                                   q Diabetes                     q Frequent ear infections                     q Hypertension
q Bleeding/clotting disorders       q Epilepsy                      q Heart defect/disease                         q Mononucleosis
q Cancer, leukemia                    q Fainting spells              q High blood pressure                         q Chicken Pox
q Motion sickness                      q Nosebleeds                 q Sleep disturbances                           Wears:      
q Emotional disturbances            q Hearing impairment     q Sickle cell trait or disease                 q Glasses/contacts
q Bed wetting                             q Constipation                q Kidney disease                                 q Dental
q Measles                                  q German Measles         q Mumps
q Convulsions                            q Frequent tonsillitis        q Other ________________________________________
q Any other condition that may require special care, medication, or diet.                                        

Explain _____________________________________________________________________________________

             _____________________________________________________________________________________


Date of last physical ________________________

Were any complicating medical problems noted in last health examination? _______________________________

For Female:
Has this person menstruated? __________ If not, has she been told about it? __________

If so, is her menstrual history normal? ________ Special consideration: ______________

Important - This box must be completed for participation.

This health history is correct so far as I know, and the person herein described has permission to engage in all Girl Scout program activities except as noted.
Signature of parent or legal guardian of minor or adult participant ___________________________________ Date ________________


Photo Release:   I agree that pictures or videos of my daughter may be used to promote Girl Scout program. 

                           q Yes          q No


Authorization for Treatment: I hereby give permission to the medical personnel selected by the Girl Scout adult in charge to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child/me.  In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Girl Scout adult in charge to secure and administer treatment, including hospitalization, for the person named above.  This completed form may be photocopied for use off-site.

Signature of parent/guardian of minor or adult participant  _______________________________________________________________________

Witness _________________________________________________________________________________ Date _________________________


I also understand and agree to abide with the restrictions placed on my Girl Scout program activities , as noted on this form.

Signature of minor or adult participant  ________________________________________________________ Date __________________________