Fillable Girl Scouts Of The Commonwealth Of Virginia Girl/adult Health History Record Form printable pdf download

Keep with troop Records

GIRL SCOUTS OF THE COMMONWEALTH OF VIRGINIA

GIRL/ADULT HEALTH HISTORY RECORD

This health history is to be completed and signed annually. Separate permission is given for emergency medical treatment/medication.

Name

Date of Birth

Telephone Number

Address

Family medical/hospital insurance carrier

Policy or Group No.

Name of Family Physician

(Area Code) Phone

Part 1: Illnesses and Injuries (check those that apply and give appropriate dates)

Weight:

Chronic or Recurring Illness

Ear Infection

Bleeding/Clotting Disorders

Hypertension

Asthma

Heart Defect/Disease

Musculoskeletal Disorders

Seizures

Diabetes

Other (specify)

Date of last health examination:

_________

Were any complicating medical problems noted in last health examination?

_______________________

Part II: Allergies (check those that apply and specify nature of allergic

Part IV: Immunization History

reaction)

Animals

Hay Fever

Immunization

Year Primary

Year of

Pollen

Food

Series Completed

Last

Booster

Medicines. Drugs

Insect stings

Tetanus

Plants

Other(specify)

Part III: Other health conditions (check those that apply)

Tuberculin test (most recent)

Result

Bed wetting

Emotional disturbances

 Immunization history is attached.

Constipation

Fainting

 All Immunizations are up-to-date

Menstrual cramps

Hearing impairment

Motion sickness

Sickle cell trait or disease

Emergency Contact: Name________________________________

Nosebleeds

Special dietary regimen

Sleep disturbances

Wears glasses or contact lenses

Relationship to Girl Scout: _________________________________

Other (specify)

Phone#_________________________________________________

Please explain any items that are checked above on back. Indicate any

Home

Cell

information useful to the adult in charge in relation to any of these health

conditions. Also indicate any activities to be encouraged or restricted.

I know of no reason(s), other than the information indicated on this form why I/my daughter should not participate in prescribed activities except as

noted.

Membership Year Oct. 1,

- Sept. 30,

Signature

Date

*(must sign here)

After review and update of forms: I have reviewed the Health History Record and updated all information. I know of no reason(s), other than the

information indicated on this form why I/my daughter should not participate in prescribed activities except as noted.

year Membership Year Oct. 1,______ - Sept. 30, _______ Signature___________________________________________ Date____________

year Membership Year Oct. 1, ______ - Sept. 30, _______ Signature___________________________________________ Date____________

I hereby give the attending adult permission to authorize and/or give emergency medical treatment.

Permission to give (please circle):

Tylenol

Simple antacid

Parent/guardian

Antihistamine Ibuprofen

*(must sign here)

In the event of a serious incident that affects the personal health, safety and welfare of girls or volunteers.

1.Give priority attention to providing all possible care for the injured person(s). 2. Secure doctor, ambulance, police and clergy as appropriate.

Call the council’s emergency number to report the emergency and to secure additional assistance - 804-254-3292

Updated 3/9/10

Girl Scouts Of The Commonwealth Of Virginia Girl/adult Health History Record Form

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