Microsoft word - gsusa_girl_health_form-1.doc

Girl Scouts of ____________ (Council Name)
Health History and Medical Examination Form for Minors
Health History: The more complete information you provide, the better we are able to work with your child to ensure she
receives the care she needs.

Medical Examination: A medical examination is completed for trips lasting more than three nights. The examination is
completed by a licensed physician, nurse practitioner, physician’s assistant or registered nurse within the preceding 24 months
unless a health issue is present.

Please type or write clearly and legibly.
Name of Minor: (Last, First, Middle Initial)
Date of Birth: (XX/XX/XXXX)
Address: City:
Parent or Guardian:
Alternate Phone:
Parent or Guardian:
Alternate Phone:
Emergency Contact Information (parent/guardian):
Emergency Contact:
Relationship:
Alternate Phone:

Health Insurance Information (Family insurance is primary insurance in case of accident or illness, Girl Scout insurance is secondary.)
Policy Holder's Name:
Policy Number:

Insurance Company Name:
Group Number:

Insurance Company Address:
Insurance Company Phone:

Check all that apply and explain in detail checked answers:
Eating Disorders (Anorexia, Bulimia, etc.) Had surgery or hospitalized in the last 5 years Please explain in detail all checked answers marked above:

Girl Name:

Allergies: Please list all allergies, the type of reaction and its severity, treatment and date of last reaction. Include allergies to
medications, food, bees, animals, plants, etc.
Allergies
Reaction/ Severity
Treatment
Date of last Reaction
Does your daughter suffer from Anaphylaxis? Yes *Anaphylaxis is a severe allergic reaction marked by swelling of the throat or tongue, hives, and trouble breathing. Medical Conditions (including any precautions or restrictions on activities)
Name of Condition

Medications: List any medications she is currently taken (or has taken in the recent past) including dosage schedule and
specific instructions for use. Also, please indicate (Yes/No) if minor is allowed to take the medication on her own or if she
should be monitored by an advisor. This would include any type of birth control.
Medication
Dosage Schedule
Specific Instructions
Self-Medicate?
(Yes/No)

Over-the-Counter Medications: My daughter has permission to take over-the-counter medications in case of accident or injury.
Please check all that she has permission to take:
Special considerations or notes
regarding over-the-counter medications:

Does your child have a Special Medical or Dietary Regiment to be followed? Yes

Have you ever had any adverse reactions to general anesthetics?

Any other information not covered in this form that is important that advisors for this trip know:

Girl Name:
(This section is to be completed by a physician after the review of health history with parent/guardian. Parent/Guardian must
complete all the information of the Health History to the best of their knowledge and sign before meeting with licensed professional.)

Medical Examination – Must be completed in detail.
Code: S = Satisfactory NS = Not Satisfactory NE = Not Examined *Girls should have this test if she had not had it since entering puberty. Record of Immunization – Must be completed in detail.

Personal and religious beliefs dictate against immunizations:

Physician Information

Licensed Physician Name: (Last, First, Middle Initial)
Phone Number:
Address: City:
This person is in satisfactory condition and may engage in all usual activities, including physically demanding activities except
as noted.

Signature of Licensed Physician:
State License Number:

HEALTH INFORMATION PRIVACY STATEMENT
The Health History and Medical Examination Form for Minors is for health care concerns at the specified event only. All
records will be handled by staff/volunteers whose job includes processing or using this information for the benefit of the
participant. All medical records will be held in limited access by the health care supervisor for the specific event. Minimal
necessary information may be shared with event staff/volunteers in order to provide adequate participant safety and health
care. This form will be retained for seven years past the age of maturity of the participant. Access to the information will be
limited, but copies may be requested from the event sponsor, by the participant or their legal representative. I have read the
above procedures for handling the health and medical form and I agree to the release of any records necessary for
treatment, referral, billing or insurance purposes.
This Health History and Medical Examination Form for Minors is complete and accurate. My daughter has permission to engage in all
prescribed activities, except as noted by me and the examining physician.
Signature of Parent/Guardian:

Source: http://www.pediatricareassociates.com/docs/GSUSA_Girl_Health_Form.pdf