Fillable Printable Personal Health and Medical Record

Personal Health and Medical Record

PERSONAL HEALTH AND MEDICAL RECORD

CLASS 1 AND CLASS 2

Height __________ Weight __________ Eye color __________ Hair color __________

I give permission for full participation in BSA programs, subject to limitations noted herein.

In case of emergency, I understand every effort will be made to contact me (if participant is an adult, my spouse or next of

kin). In the event I cannot be reached, I hereby give my permission to the licensed health-care practitioner selected by the

adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication

for my child (or for me, if participant is an adult).

Date______________ Signature of parent/guardian or adult __________________________________________________

Date updated______________ Signature of parent/guardian or adult __________________________________________

Date updated______________ Signature of parent/guardian or adult ___________________________________________

Some hospitals require the parent/guardian signature to be notarized. Check with your BSA local council.

NAME ___________________________________________________________ TROOP_________________________ CAMPSITE_________________________

CLASS 1 PERSONAL HEALTH AND MEDICAL HISTORY

(To be filled out annually by all participants)

To be filled out by parent, guardian, or adult participant. Please print in ink.

IDENTIFICATION

Name ____________________________________________________ Date of birth_______________ Age_______ Sex_______

Name of parent or guardian _____________________________________________________ Telephone__________________

Home address __________________________________ City_______________________ State__________ Zip_____________

Business address ______________________________ City_______________________ State__________ Zip_____________

If person named above is not available in the event of an emergency, notify

Name _______________________________________ Relationship____________________ Telephone____________________

Name of personal physician ____________________________________________________ Telephone____________________

Personal health/accident insurance carrier ________________________________________ Policy No.____________________

Check all items that apply, past or present, to your health history. Explain any “Yes” answers.

ALLERGIES: Food, medicines, insects, plants Yes ■ No ■ Explain: ____________________________________________

GENERAL INFORMATION: Yes No Yes No Yes No

ADHD (Attention-Deficit

Hyperactivity Disorder)

■ ■ Convulsions/seizures ■ ■ Hemophilia ■ ■

Asthma ■ ■ Diabetes ■ ■ High blood pressure ■ ■

Cancer/leukemia ■ ■ Heart trouble ■ ■ Kidney disease ■ ■

Explain: _______________________________________________________________________________________________

Please list ALL medications taken in the 30 days prior to arrival at the Scouting activity where this form is to be used: _________

______________________________________________________________________________________________________

List any medications to be taken at camp, including drug, dosage, route (oral, injection, etc.), and frequency: ______________

______________________________________________________________________________________________________

List any physical or behavioral conditions that may affect or limit full participation in swimming, backpacking, hiking long distances,

or playing strenuous physical games: ________________________________________________________________________

List equipment needed such as wheelchair, braces, glasses, contact lenses, etc.: ______________________________________

Immunizations: (Give date of last inoculation.)

Tetanus toxoid ____________________ Measles ___________________ Polio _____________________

OR DPT ____________________ OR MMR ___________________ _________________________

Hepatitis A ____________________ Varicella ___________________ OR Chicken pox ____________

Hepatitis B ____________________

If your child has had a medical evaluation (physical examination) within the last 36 months, a copy of the results of this exami-

nation must be attached to the health history for all participants in a camping experience lasting longer than 72 consecutive hours.

If a copy is not available, a physical examination (using the Class 2 section of this form) must be scheduled by a *licensed health-

care practitioner. This medical evaluation (physical examination) also is required if your child is currently under medical care,

takes a prescribed medication, requires a medically prescribed diet, has had an injury or illness during the past 6 months

that limited activity for a week or more, has ever lost consciousness during physical activity, or has suffered a concussion

from a head injury.

* Examinations conducted by licensed health-care practitioners, other than physicians, will be recognized for BSA purposes in

those states where such practitioners may perform physical examinations within their legally prescribed scope of practice.

THIS FORM IS NOT TO BE USED BY ADULTS OVER 40, BY HIGH-ADVENTURE PARTICIPANTS (USE FORM

NO. 34412A), OR FOR NATIONAL SCOUT JAMBOREE (USE FORM NSJ-34412-01).

CLASS 2 MEDICAL EVALUATION

(Read additional requirements outlined on front of form.)

Name ____________________________________________________________________________________ Age_________

NOTE TO LICENSED HEALTH-CARE PRACTITIONERS*: The person being evaluated will be attending one or more weeks of

camp that may include sleeping on the ground and participating in strenuous activities such as hiking, boating, and vigorous group

games. Please review the health history with the participant for any interim changes. Explain any “abnormal” evaluations.

PHYSICAL EXAMINATION (To be filled out by a licensed health-care practitioner*)

Height ________________________ Weight______________________ BP________

________ Pulse____________________

VISION: Normal ___________________ Glasses ____________________________ Contacts ___________________

HEARING: Normal ___________________ Abnormal ____________________________ Explain ____________________

Check box: N Abn N Abn N Abn

Growth development

■ ■ Teeth ■ ■ Genitalia ■ ■

Skin ■ ■ Cardiopulmonary system ■ ■ Musculoskeletal ■ ■

HEENT ■ ■ Hernia ■ ■ Neurobehavioral ■ ■

Explain: _______________________________________________________________________________________________

Limitations

Activity restrictions _______________________________________________________________________________________

Diet restrictions _________________________________________________________________________________________

Comment on any need for medical assistance devices: __________________________________________________________

Signature ____________________________________ Printed name _________________________ Date______________

Licensed health-care practitioner*

Address _____________________________________________________________________ Phone__________________

City, State, Zip __________________________________________________________________________________________

* Examinations conducted by licensed health-care practitioners, other than physicians, will be recognized for BSA

purposes in those states where such practitioners may perform physical examinations within their legally prescribed

scope of practice.

Note: Some states require an annual precamp medical evaluation. Your BSA local council service center can advise

you about the requirements for your state.

NAME ___________________________________________________________ TROOP_________________________ CAMPSITE_________________________

34414B

2007 Printing

INTERVAL RECORD

SCREENING EXAMINATION

Date, Time, Place, Etc. (Findings, diagnoses, treatment, instructions, disposition, etc.) By

PHOTOCOPYING THIS FORM IS PERMITTED.

030176 34414

#34414B

Class 1 (update annually for all participants). Activity: Day camp, overnight hike, or other programs not exceeding 72 hours,

with level of activity similar to that of home or school. Medical care is readily available. 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.

Class 2 (required once every 36 months for all participants under 40 years of age). Activity: Resident camp or any other

activity such as backpacking, tour camping, or recreational sports involving events lasting longer than 72 consecutive hours,

with level of activity similar to that at home or school. Medical care is readily available.