Fillable Printable Annual Health and Medical Record
Fillable Printable Annual Health and Medical Record
Annual Health and Medical Record
Annual Health and Medical Record
(Valid for 12 calendar months)
Medical Information
The Boy Scouts of America recommends that all youth and adult members have annual medical evaluations
by a certified and licensed health-care provider. In an effort to provide better care to those who may become
ill or injured and to provide youth members and adult leaders a better understanding of their own physical
capabilities, the Boy Scouts of America has established minimum standards for providing medical information
prior to participating in various activities. Those standards are offered below in one three-part medical form.
Note that unit leaders must always protect the privacy of unit participants by protecting their medical information.
Parts A and C
are to be completed annually by all BSA unit members. Both parts are required for all events
that do not exceed 72 consecutive hours, where the level of activity is similar to that normally expended at home
or at school, such as day camp, day hikes, swimming parties, or an overnight camp, and where medical care is
readily available. Medical information required includes a current health history and list of medications. Part C
also includes the parental informed consent and hold harmless/release agreement (with an area for notarization if
required by your state) as well as a talent release statement. Adult unit leaders should review participants’ health
histories and become knowledgeable about the medical needs of the youth members in their unit. This form is to
be filled out by participants and parents or guardians and kept on file for easy reference.
Part B
is required with parts A and C for any event that exceeds 72 consecutive hours
, a resident camp
setting, or when the nature of the activity is strenuous and demanding, such as service projects, work
weekends, or high-adventure treks. It is to be completed and signed by a certified and licensed health-care
provider—physician (MD, DO), nurse practitioner, or physician’s assistant as appropriate for your state. The
level of activity ranges from what is normally expended at home or at school to strenuous activity such as
hiking and backpacking. Other examples include tour camping, jamborees, and Wood Badge training courses.
It is important to note that the height/weight chart must be strictly adhered to if the event will take the unit
beyond a radius wherein emergency evacuation is more than 30 minutes by ground transportation, such as
backpacking trips, high-adventure activities, and conservation projects in remote areas.
Risk
Factors
Based on the vast experience of the medical community, the BSA has identified that the following risk factors
may define your participation in various outdoor adventures.
Exc•essive body weight
Heart disease•
Hypertension (high blood pressure)•
Diabetes•
Seizures•
Lack of appropriate immunizations•
Asthma•
Sleep disorders•
Allergies/anaphylaxis•
Muscular/skeletal injuries•
Psychiatric/psychological and emotional difficulties•
For more information on medical risk factors, visit Scouting Safely on
www.scouting.org.
Prescriptions
The taking of prescription medication is the responsibility of the individual taking the medication and/or that
individual’s parent or guardian. A leader, after obtaining all the necessary information, can agree to accept the
responsibility of making sure a youth takes the necessary medication at the appropriate time, but BSA does not
mandate or necessarily encourage the leader to do so. Also, if state laws are more limiting, they must be followed.
Last name: ________________________________ DOB: ______________ Allergies: __________________ Emergency contact No.: ___________________
Annual BSA Health and Medical Record
Part A
GENERAL INFORMATION
Name ________________________________________Date of birth ________________________________ Age _____________ Male Female
Address ____________________________________________________________________________________ Grade completed (youth only) __________
City ________________________________State ____________ Zip ____________________________ Phone No. ________________________________
Unit leader _____________________________ Council name/No. ___________________________________________ Unit No. ___________________
Social Security No. (optional; may be required by medical facilities for treatment) _______________ Religious preference ______________________________
Health/accident insurance company _______________________________ Policy No. ________________________________________________________
ATTACH A PHOTOCOPY OF BOTH SIDES OF INSURANCE CARD (SEE PART C).
IF FAMILY HAS NO MEDICAL INSURANCE, STATE “NONE.”
In case of emergency, notify:
Name ________________________________________________ Relationship _____________________________________________________________
Address _________________________________________________________________________________________________________________________
Home phone _________________________________________ Business phone _______________________________ Cell phone __________________
Alternate contact _________________________________________________________________________ Alternate’s phone _______________________
MEDICAL HISTORY
Are you now, or have you ever been treated for any of the following:
Allergies or Reaction to:
YesNoConditionExplain
Medication _________________________________
Food, Plants, or Insect Bites __________________
____________________________________________
Immunizations:
The following are recommended by the BSA.
Tetanus immunization must have been received
within the last 10 years. If had disease, put “D”
and the year. If immunized, check the box and
enter the year received.
Yes No Date
Tetanus __________________________
Pertussis ________________________
Diptheria _________________________
Measles _________________________
Mumps __________________________
Rubella __________________________
Polio ____________________________
Chicken pox_______________________
Hepatitis A ________________________
Hepatitis B ________________________
Influenza ________________________
Exemption to immunizations claimed.
(For more information about immunizations, as
well as the immunization exemption form, see
Scouting Safely on Scouting.org.)
Asthma
Diabetes
Hypertension (high blood pressure)
Heart disease (i.e., CHF, CAD, MI)
Stroke/TIA
COPD
Ear/sinus problems
Muscular/skeletal condition
Menstrual problems (women only)
Psychiatric/psychological and
emotional difficulties
Learning disorders (i.e., ADHD, ADD)
Bleeding disorders
Fainting spells
Thyroid disease
Kidney disease
Sickle cell disease
Seizures
Sleep disorders (i.e., sleep apnea)
GI problems (i.e., abdominal, digestive)
Surgery
Serious injury
Other
MEDICATIONS
List all medications currently used. (If additional space is needed, please photocopy this part of the health form.)
Inhalers and EpiPen information must be included, even if they are for occasional or emergency use only.
Medication _______________________________________
Strength ___________ Frequency __________________
Reason for medication __________________________
_____________________________________________________
Approximate date started ______________________
Temporary Permanent
Medication _______________________________________
Strength ___________ Frequency __________________
Reason for medication __________________________
_____________________________________________________
Approximate date started ______________________
Temporary Permanent
Medication _______________________________
Strength ___________ Frequency __________
Reason for medication _____________________
_________________________________________
Approximate date started __________________
Temporary Permanent
Medication _______________________________________
Strength ___________ Frequency __________________
Reason for medication __________________________
_____________________________________________________
Approximate date started ______________________
Temporary Permanent
Medication _______________________________________
Strength ___________ Frequency __________________
Reason for medication __________________________
_____________________________________________________
Approximate date started ______________________
Temporary Permanent
Medication _______________________________
Strength ___________ Frequency __________
Reason for medication _____________________
_________________________________________
Approximate date started _________________
Temporary Permanent
NOTE: Be sure to bring medications in the appropriate containers, and make sure that they are NOT expired,
including inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance medication.
Part B
PHYSICAL EXAMINATION
Height ___________ Weight ____________ Meets height/weight limits Yes No Blood pressure __________ Pulse _____________
Individuals desiring to participate in any high-adventure activity or events in which emergency evacuation would take longer
than 30 minutes by ground transportation will not be permitted to do so if they exceed the weight limit as documented at the
bottom of this page. Enforcing the height/weight limit is strongly encouraged for all other events, but it is not mandatory.
(For healthy height/weight guidelines, visit
www.cdc.gov
.)
NormalAbnormal
Explain Any
Abnormalities
Range of MobilityNormalAbnormal
Explain Any
Abnormalities
EyesKnees (both)
EarsAnkles (both)
NoseSpine
Throat
Lungs
OtherYesNo
HeartContacts
AbdomenDentures
GenitaliaBraces
SkinInguinal hernia
Explain
Emotional
adjustment
Medical equipment
(i.e., CPAP, oxygen)
Allergies (to what agent, type of reaction, treatment): _________________________________________________________________________
________________________________________________________________________________________________________________________
I certify that I have, today, reviewed the health history, examined this person, and approve this individual for participation in:
Hiking and camping Competitive activities Backpacking Swimming/water activitiesClimbing/rappelling
Sports Horseback riding Scuba diving Mountain biking Challenge (“ropes”) course
Cold-weather activity (<10°F) Wilderness/backcountry treks
Specify restrictions (if none, so state) ______________________________________________________________________________________
________________________________________________________________________________________________________________________
Certified and licensed health-care providers recognized by the BSA to perform this exam include physicians (MD, DO), nurse
practitioners, and physician’s assistants.
To Health Care Provider: Restricted approval includes:
➔Uncontrolled heart disease, asthma, or hypertension.
➔Uncontrolled psychiatric disorders.
➔Poorly controlled diabetes.
➔Orthopedic injuries not cleared by a physician.
➔Newly diagnosed seizure events (within 6 months).
➔
For scuba, use of medications to control diabetes, asthma,
or seizures
Provider printed name ______________________________________
Signature _________________________________________________
Address __________________________________________________
City, state, zip _____________________________________________
Office phone ______________________________________________
Date _____________________________________________________
Height
(inches)
Recommended
Weight (lbs)
Allowable
Exception
Maximum
Acceptance
6097-138139-166166
61101-143144-172172
62104-148149-178178
63107-152153-183183
64111-157158-189189
65114-162163-195195
66118-167168-201201
67121-172173-207207
68125-178179-214214
69129-185186-220220
Height
(inches)
Recommended
Weight (lbs)
Allowable
Exception
Maximum
Acceptance
70132-188189-226226
71136-194195-233233
72140-199200-239239
73144-205206-246246
74148-210211-252252
75152-216217-260260
76156-222223-267267
77160-228229-274274
78164-234235-281281
79 & over170-240241-295295
This table is based on the revised Dietary Guidelines for Americans from the U.S. Dept. of Agriculture and the Dept. of Health & Human Services.
Part BLast name: _________________________________________ DOB: ___________________
Part C
Parental Informed Consent and Hold Harmless/Release Agreement
I understand that participation in Scouting activities involves a certain degree of risk. I have carefully considered the risk involved and
have given consent for myself or my child to participate in these activities. I understand that participation in these activities is entirely
voluntary and requires participants to abide by applicable rules and standards of conduct. I release the Boy Scouts of America, the
local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the
activity from any and all claims or liability arising out of this participation.
I approve the sharing of the information on this form with BSA volunteers and professionals who need to know of medical situations
that might require special consideration for the safe conducting of Scouting activities.
In case of an emergency involving me or my child, I understand that every effort will be made to contact the individual listed as the
emergency contact person. In the event that this person cannot be reached, permission is hereby given to the medical provider
selected by the adult leader in charge to secure proper treatment, including hospitalization,anesthesia, surgery, or injections of
medication for me or my child. Medical providers are authorized to disclose to the adult in charge examinationfindings, test results,
and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with theparticipant’s
parents or guardian, and/or determination of the participant’s ability to continue in the program activities.
Without restrictions.
With special considerations or restrictions (list) ______________________________________________________________________________
___________________________________________________________________________________________________________________________
Talent Release Form
I hereby assign and grant to the local council and the Boy Scouts of America the right and permission to use and publish the
photographs/film/videotapes/electronic representations and/or sound recordings made of me or my child by the Boy Scouts of
America, and I hereby release the Boy Scouts of America from any and all liability from such use and publication.
I hereby authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/
film/videotapes/electronic representations and/or sound recordings without limitation at the discretion of the Boy Scouts of America,
and I specifically waive any right to any compensation I may have for any of the foregoing.
Yes No
I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity
for participation in any event or activity.
Participant’s name __________________________________________________________________________________________________________
Participant’s signature _______________________________________________________________________________________________________
Parent/guardian’s signature __________________________________________________________________________________________________
(if under the age of 18)
Date ________________________________________________
Attach copy of insurance card (front and back) here. If required byyour state, use the space provided here for notarization.
