MedicineLakex

 

Girl scouts health history and medical examination form for adults

1700 WaterMark Drive Columbus, OH 43215-1097 Phone: (614) 487-8101 Tol -Free in Ohio (800) 621-7042 Fax: (614) 487-8189 Girl Scouts Health History and
Medical Examination Form for Adults
Health History: The more complete information you provide, the better we are able to work with you to ensure you
receive the care you need.
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 Adult: (Last, First, Middle Initial)
Date of Birth: (XX/XX/XXXX)
Address:
Spouse (if applicable):
Alternate Phone:
Emergency Contact Information:
Emergency Contact:
Alternate Phone:

Health Insurance Information (Family insurance is primary insurance in case of accident or il ness, Girl Scout insurance is
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:
 Eyesight Impairment  Heart Defects/Disease  Hearing Impairment  Asthma or Hay Fever  Speech Impairment  Diseases of the Ears or Ear Infections  Intestinal Disorders/Constipation  Musculoskeletal Disorders  Convulsions/Epilepsy/Seizures  Sinusitis (Sinus Infections)  German Measles  Physical Restrictions  Kidney/bladder illness  Rheumatic Fever  Mental/psychological disorder  Tuberculosis  Hypertension/Abnormal Blood Pressure  Kidney Disease  Eating Disorders (Anorexia, Bulimia, etc.)  Headaches/Migraines  Had surgery or hospitalized in the last 5 years  Menstrual cramps  Currently under doctor's care  Bleeding disorder Please explain in detail al checked answers marked above:

Adult Name:

Allergies: Please list al al ergies, the type of reaction and its severity, treatment and date of last reaction. Include
al ergies to medications, food, bees, animals, plants, etc. Allergies
Reaction/ Severity
Treatment
Date of last Reaction
Do you suffer from Anaphylaxis? *Anaphylaxis is a severe al ergic reaction marked by swelling of the throat or tongue, hives, and trouble breathing. Do you carry an Epipen? Do you carry an inhaler? Medical Conditions (including any precautions or restrictions on activities)
Name of Condition

Medications: List any medications currently taken (or has taken in the recent past) including dosage schedule and
specific instructions for use. Medication
Dosage Schedule
Specific Instructions

Over-the-Counter Medications: In case of accident or injury. Please check al that apply:
 Tylenol/Acetaminophen  Imodium (anti-diarrhea) Special considerations or notes regarding
 Aspirin (fever reducer)  Dramamine (motion sickness over-the-counter medications:
 Ibuprofen (pain/swel ing)  Benadryl/Antihistamine  Skin Ointments (in case of rash, antibacterial, athlete's foot, etc.)  Robitussin/expectorant  Sudafed/decongestant  Pepto Bismol  Tums/antacid
Do you have a Special Medical or Dietary Regiment to be followed?
If so, please explain:
Have you ever had any adverse reactions to general anesthetics? Yes No
If so, please explain:
Additional information that is important for other advisors on this trip to know about:

Adult Name:
(This section is to be completed by a physician after the review of health history. Adult must complete all the information in the Health History to the best of their knowledge and sign before meeting with licensed professional.)
Medical Examination
Pulse Rate: B. P.: / Albumin: Blood Hemoglobin: Eyes: With Glasses R 20/ L 20/ Without Glasses R 20/ L 20/ Code: S = Satisfactory NS = Not Satisfactory NE = Not Examined Appearance/Nutrition General Physical State Musculoskeletal General Emotional State *Girls should have this test if she had not had it since entering puberty. Does this applicant have any conditions which might limit activity for this event/travel/assignment; such as chronic disease, weight or limit participation in swimming or other strenuous activity? Yes If yes, please explain:
Record of Immunization
was Completed Last Booster was Completed Last Booster Tuberculin Test: Year last given Not required immunizations, but recommended
Physician Information
Licensed Physician Name: (Last, First, Middle Initial)
Phone Number:
Address:
This person is in satisfactory condition and may engage in all usual activities, including physical y demanding activities except
Signature of Licensed Physician:
State License Number:

HEALTH INFORMATION PRIVACY STATEMENT
The Adult Health History and Medical Examination Form 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 in the case of treatment. 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 Adult Health History and Medical Examination Form is complete and accurate.

Signature of Adult Participant:

Source: http://www.hilliardgirlscouts.org/dnn/LinkClick.aspx?fileticket=TMJCbHNoBKI%3D&tabid=257