Adult Health History Card - Girl Scouts Of Connecticut
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1
2Please cut and distribute to adults in your Troop/Group and Service Team.
Card should be carried in your wallet at all times.
(800) 922-2770
(800) 922-2770
(800) 922-2770
Adult Health History
Adult Health History
Adult Health History
Name:______________________________________________________
Name:______________________________________________________
Name:______________________________________________________
Any chronic or recurring illness (convulsions, diabetes, asthma, etc.)
Any chronic or recurring illness (convulsions, diabetes, asthma, etc.)
Any chronic or recurring illness (convulsions, diabetes, asthma, etc.)
____________________________________________________________
____________________________________________________________
____________________________________________________________
Date of last tetanus shot:________________________________________
Date of last tetanus shot:________________________________________
Date of last tetanus shot:________________________________________
List any allergies (penicillin, aspirin, insect bites, etc.)
List any allergies (penicillin, aspirin, insect bites, etc.)
List any allergies (penicillin, aspirin, insect bites, etc.)
____________________________________________________________
____________________________________________________________
____________________________________________________________
Note any medication normally carried and for what and how it should be
Note any medication normally carried and for what and how it should be
Note any medication normally carried and for what and how it should be
administered:_________________________________________________
administered:_________________________________________________
administered:_________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
(800) 922-2770
(800) 922-2770
(800) 922-2770
Adult Health History
Adult Health History
Adult Health History
Name:______________________________________________________
Name:______________________________________________________
Name:______________________________________________________
Any chronic or recurring illness (convulsions, diabetes, asthma, etc.)
Any chronic or recurring illness (convulsions, diabetes, asthma, etc.)
Any chronic or recurring illness (convulsions, diabetes, asthma, etc.)
____________________________________________________________
____________________________________________________________
____________________________________________________________
Date of last tetanus shot:________________________________________
Date of last tetanus shot:________________________________________
Date of last tetanus shot:________________________________________
List any allergies (penicillin, aspirin, insect bites, etc.)
List any allergies (penicillin, aspirin, insect bites, etc.)
List any allergies (penicillin, aspirin, insect bites, etc.)
____________________________________________________________
____________________________________________________________
____________________________________________________________
Note any medication normally carried and for what and how it should be
Note any medication normally carried and for what and how it should be
Note any medication normally carried and for what and how it should be
administered:_________________________________________________
administered:_________________________________________________
administered:_________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
(800) 922-2770
(800) 922-2770
(800) 922-2770
Adult Health History
Adult Health History
Adult Health History
Name:______________________________________________________
Name:______________________________________________________
Name:______________________________________________________
Any chronic or recurring illness (convulsions, diabetes, asthma, etc.)
Any chronic or recurring illness (convulsions, diabetes, asthma, etc.)
Any chronic or recurring illness (convulsions, diabetes, asthma, etc.)
____________________________________________________________
____________________________________________________________
____________________________________________________________
Date of last tetanus shot:________________________________________
Date of last tetanus shot:________________________________________
Date of last tetanus shot:________________________________________
List any allergies (penicillin, aspirin, insect bites, etc.)
List any allergies (penicillin, aspirin, insect bites, etc.)
List any allergies (penicillin, aspirin, insect bites, etc.)
____________________________________________________________
____________________________________________________________
____________________________________________________________
Note any medication normally carried and for what and how it should be
Note any medication normally carried and for what and how it should be
Note any medication normally carried and for what and how it should be
administered:_________________________________________________
administered:_________________________________________________
administered:_________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
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