Girl Scouts Western Pennsylvania Camp Health History Form
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1
2HEALTH HISTORY FORM
UNIT:________
Health Screening
(For Office Use Only)
1.
How are you feeling today?
2.
Have you recently had or been exposed to pink eye, head lice, or the
Camp Attending: ___________________________________
flu?
3.
Do you have any fevers, rashes, or allergies that we should know
about?
Session(s): _______________________________________
4.
Are there any updates to the health form?
Dates: ___________________________________________
Screening________ Head Check________
This part is to be filled out by the parent/guardian.
Name (Last, First, Initial)
Sex
Birth Date
Age
Address
City or Town
State
Zip
Phone
(
)
Parent/Guardian #1
Parent/Guardian #1 Phone
Parent/Guardian #2
Parent/Guardian #2 Phone
(
)
(
)
Emergency Contact other than Parent
Relationship
Phone
Alternate Phone
(
)
(
)
Insurance Information
Please complete the following:
-
Carrier
ID Number
Group Number
Member Services Phone Number
Address
(
)
Primary Care Physician Phone
Primary Care Physician
(
)
Health History – Please check if you have had any of the following:
ALLERGIES
ADD/ADHD
ILLNESS/HEALTH CONDITIONS
My daughter has permission to
Ear Infections
Animals______________________
take or use the following:
Chicken Pox
Food ________________________
Heart Defect/Disease
Tylenol/Acetaminophen
Measles
Hay Fever____________________
Seizures
Advil/Ibuprofen
German Measles
Insect Bites/Stings______________
Bleeding Disorders
Sudafed/Decongestant
Mumps
Medicine/Drugs ________________
Asthma
Benadryl/Antihistamine
Rheumatic Fever
Pollen________________________
Hypertension
Tuberculosis
Tums/Antacid
Other (Specify) ________________
Diabetes
Robitussin/Expectorant
Hepatitis
Musculoskeletal
Calamine Lotion/Itch Relief
HIV/AIDS
Disorders
Cough Drops
Kidney Disease
Arthritis
Midol/Menstrual Cramp Relief
Mononucleosis
Sinusitis
Aloe Vera
Hearing Impairment
Eating Disorders
Bacitracin
Contacts/Glasses
Other_______________
Migraines
Immodium
Desinex/Tinactin Powder
Please describe conditions and give dates:
Does the participant currently have tubes in their ears? ___ No ___ Yes
If yes, how long have they been in?
Any operations or serious injuries?
Any hospitalizations?
Any other diseases or disabilities?
Please comment where applicable:
Fainting
Sleeping Disturbances/Disorders
Bedwetting
Menstrual Cramps
Constipation
Severe Nosebleeds
Emotional Disturbances
Other
Specific Activities to be Encouraged
Restricted
Dietary Regimen to be Followed
Please describe any current physical, mental, or psychological conditions requiring medication, treatment, or special restrictions or considerations while at
camp
________
_
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