Personal Health And Medical Record Form
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Personal Health and Medical Record Form
Adult
Girl
Age _____
Gender (if adult) ______
Update annually for all participants
Activity: Troop meetings, overnight trips, or other programs not exceeding 72 hours. Current personal health and medical summary
(history) is attested by parents to be accurate. This form is filled out by all participants and is on file for easy reference. (Attach
separate page if necessary). To be filled out by parent, guardian, or adult participant annually. Please fill out electronically or print in ink .
Participant Information
Medical Authorization
Date of Birth
I give permission for full participation in GSNEO programs.
Name _________________________
_____________
In the event that I and the other Emergency Contacts listed
(Last)
(First)
Mo
Day Year
below cannot be contacted, I hereby give my permission to
Address ________________________________________
the licensed health-care practitioner selected by the adult
leader in charge to secure proper treatment, including
City & State _______________________ Zip __________
hospitalization, anesthesia, surgery, or injections of
medication for my child (or for me, if participant is an adult).
Parent / Guardian Information
Signature ___________________________ Date _________
Girl is under custodial care of:
(Parent / guardian or adult)
Both parents
Guardian(s)
Mother only
Father only
Emergency Contact Information
In addition to the parent(s)/guardian(s) listed, this girl may
Parent/Guardian Name __________________________________
be released to the following person(s):
Address
Name ____________________________________
______________________________________________
Relationship: ____________ Phone __________________
Phone
__________________________________ (day)
Name ____________________________________
__________________________________ (evening)
Relationship: ____________ Phone __________________
Personal Physician
Medical History
Name __________________________ Phone __________
Date of most recent physical exam: _______________________
Insurance Carrier _________________________________
Are you aware of any current health problems?
Policy # ______________________ Phone ____________
Now under medical care of taking medication?
Insured name (parent) _____________________________
In the last 6 months – have any of these happened:
Dentist
Any surgery, illness, allergy or other change?
Name __________________________ Phone __________
Hospitalizations or serious injuries?
Insurance Carrier _________________________________
Give dates and full details for any “yes” answers here:
Policy # ______________________ Phone ____________
____________________________________________________
Insured name (parent) _____________________________
____________________________________________________
Allergies (check all that apply)
Immunizations
(year)
Current Medications ___________________________________
__ Animals
__ Plants
Tetanus _________
Being taken for (condition) _______________________________
__ Food(s)
__ Pollen
Measles _________
Dosage and frequency __________________________________
__ Hay Fever
__ Other
Rubella
_________
__ Insect Stings
Mumps
_________
Chronic or Recurring Conditions (check all that apply)
__ Asthma
__ Heart disease / defect
__ Medicine/drugs
Diphtheria ________
Pertussis _________
__ Bleeding Disorders
__ Urinary Infection
Please provide details of any checked
Hepatitis B________
__ Convulsions / Seizures
__ Vision – Contacts / Glasses
(Attach separate page if necessary):
TB Test _________
__ Diabetes
__ Teeth – dentures / bridge
_____________________________________
Other
_________
__ Ear Infection
__ Menstrual problems
_____________________________________
__ Emotional / behavior disturbance __ Fainting
__ Hypertension
__ Other
Medical Authorization
Please provide details for any items checked (attach separate
I give permission for First Aider to administer to my daughter/ward/me,
page if necessary).
according to instructions printed on the original container, the following over-
_____________________________________________________
the-counter and/or prescription medications which I have provided in their
original containers. Check all that apply:
_____________________________________________________
___ Acetaminophen (Tylenol)
___ Ibuprofen (Motrin)
Special Needs
___ Antacid (Mylanta, Tums)
___ Oral anesthetic
Dietary
___ Hydrocortisone cream
___ Antihistamine (Benadryl)
_____________________________________________________
___ Cough suppressant (Robitussin)
___ Eye wash
_____________________________________________________
___ Antibiotic cream (Neosporin)
___ Sunscreen
Activities to be restricted _________________________________
___ Calamine lotion
___ Insect repellent
_____________________________________________________
___ Other
_____________________________________________________
Prescription medications (attach separate page if necessary) ______________
_______________________________________________________________
This Health History is complete and accurate. My daughter/I have
_______________________________________________________________
permission to engage in all prescribed activities except as noted
above.
Signature ___________________________________ Date ______________
Signature ___________________________ Date ____________
(Parent / guardian or adult)
(Parent / guardian or adult)
Revised 1/11
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