GIRL SCOUTS OF NORTHERN CALIFORNIA
CAMPER HEALTH RECORD AND EMERGENCY INFORMATION
This part to be filled in by adult and reviewed with practioner at the time of examination
Name (Last, First, Initial)
Birth Date
Grade
Address
City/Town
State
Zip
Phone
(
)
Parent/Guardian’s
(1) Name
E-Mail Address (For GSNC use only)
Home Phone
(
)
Place of work
Title
Work Phone
(
)
Parent/Guardian’s
(2) Name
E-Mail Address (For GSNC use only)
Home Phone
(
)
Place of work
Title
Work Phone
(
)
Name of Alternate Emergency Contact If Parent/Guardian are Unavailable
Relationship
Home Phone
(
)
Address
City/Town
State
Zip
Work Phone
(
)
INSURANCE INFORMATION, PLEASE COMPLETE THE FOLLOWING:
Carrier
ID Number
Group Number
Member Services Phone Number
Address
City/Town
State
Zip
(
)
HEALTH HISTORY: (Check those that apply)
SUGGESTION FROM
DISEASES:
ALLERGIES:
CHRONIC or
APPLIANCES:
PARENT/GUARDIAN:
Chicken Pox
Animals:____________
RECURRING ILLNESS:
Hearing Aid
My daughter has
Measles
Food: ______________
Ear Infections
Orthopedic Braces
permission to take or
German Measles
Hay Fever
Heart Defect/Disease
Glasses
use the following:
Mumps
Insect Stings
Seizures
Contact Lenses
Tylenol/Acetaminophen
Rheumatic Fever
Medicine/Drugs:______
Bleeding Disorders
Dental Braces
Advil/Ibuprofen
Tuberculosis
Plants:______________
Asthma
Retainer
Sudafed/decongestant
Kidneys
Pollen
Hypertension
Other
:__________
Benadryl/antihistamine
(specify)
Other
:
Diabetes
____________________
Pepto Bismol
(specify)
Musculoskeletal
Tums/antacid
____________________
____________________
Disorders
Robitussin/expectorant
____________________
____________________
Arthritis
Swimmer’s Ear/alcohol-
____________________
____________________
Sinusitis
vinegar solution
____________________
____________________
Other
Cough drops
(specify):
DETAILS OF ANY CHECKED ITEMS ABOVE (i.e. allergic reactions to bee stings, food, or medications/drugs)
PLEASE DESCRIBE CONDITIONS AND GIVE DATES:
Operations or serious injuries:
Hospitalizations:
List any other diseases or disabilities:
Fainting
Sleep Disturbances
Bed Wetting
Menstrual Cramps
Constipation
Nosebleeds
Emotional Disturbances
Other (Specific)
Specific Activities to be Encouraged
Restricted
Any known recent exposure to contagious disease(s) within the last 6 weeks? YES
NO
If YES, give details:
Have you talked to your girl about menstruation? YES
NO
Has she started menstruating? YES
NO
Is your child currently under care of physician or psychologist? YES
NO
If YES, give details:
Special medical or dietary regimen to be followed (specify):
PARENT CONSENT: This Camper Health Record and Emergency Information is complete and accurate to my
knowledge. My daughter has permission to engage in all prescribed activities, except as noted by me and by
the examining physician. I give permission for her to receive emergency medical and surgical treatment and to
be hospitalized, if necessary. It is understood that every effort will be made to contact me or the person(s)
noted above before taking this action.
SIGNATURE OF PARENT/GUARDIAN:
DATE: