Health History & Health Examination Form
DEADLINE:  June 15, 2005
TO BE COMPLETED BY PARENT/GUARDIAN  PLEASE PRINT    

Girl’s Name:   Birthdate:  Age:

Mailing Address:

Street Address:

Parent/Guardian:  Phone (wk):   (hm):

Parent/Guardian:  Phone (wk):   (hm):

Additional Emergency Contact:   Name: _

                                       Phone (wk): Phone (hm):

Doctor or Clinic:   Phone:

Health Plan:   Group No.:

If Military:         Sponsor’s Name: _

  Sponsor’s Soc. Sec.:   Rank:   Unit:

ALLERGIES:                                         

Hay Fever

 Measles Deformities

Insect Sting

 German Measles Limb Brace

Medicine/Drugs

 Mumps Special Shoes

 Plants

 Asthma Dental Braces

Food (Specify)

 Hepatitis Glasses

Pollen

 Rheumatic Fever Hearing Aid

Animals

 Diabetes Ear Infections

Other (Specify)

 Epilepsy Convulsions

Chicken Pox

 Fainting Other (Specify)

OTHER HEALTH CONDITIONS:  (Give approximate dates) 
 Additional Details:

Special care you give at home:

SPECIAL THINGS YOUR CHILD MAY NEED HELP WITH AT CAMP:

Behavior problems  

IMMUNIZATIONS:  (Give dates)

DPT

Tetanus Booster

Oral Polio

Measles/Rubella

TB Tine 

Other

Fear of dark  
Sleepwalking  
Bedwetting  
Recent Operation  
Chronic or Recurring Illness  
Stomach aches & pains  
Growing Pains  
Selective Eater  
Never been away from home alone  

Is there any restriction on physical activity? Explain:

Has this camper menstruated?     Yes   No     If not, has she been told? Yes No

If so, is her menstrual history normal?  Yes No   Does she have problems with cramps? Yes No

List below all medications your camper will be taking to camp, including aspirin and cough drops:

List below all medications your camper will be taking to camp, including aspirin and cough drops:

What Why Instructions

PARENT AUTHORIZATION:

This health history is correct to the best of my knowledge, and the camper herein described is free of any potential health problems that might restrict participation at camp (except as noted by me and/or the physician) and is free of any communicable diseases that might endanger other campers.
 In the event I cannot be reached in an emergency, I hereby give permission for emergency care to be given.  This authorization applies whether the charges are covered by Girl Scout insurance or by myself.  I give this authorization with knowledge that Girl Scout health insurance is secondary and does not provide coverage for every incident.

PARENT/GUARDIAN’S SIGNATURE:
  DATE:

MEDICAL EXAMINATION – TO BE FILLED OUT BY DOCTOR

Camper’s Name: _____________________________________________________________

 Height: _____  Weight: ______  Temperature: ____ Blood Pressure:_____  Pulse: ____

 Examination findings – please check box if condition is satisfactory.  If not, please explain.

Eyes & Vision
 Skin

Throat
 Ears & Hearing

Heart
 Lungs

Legs
 Abdomen

 I find this camper in good physical condition for camping, hiking, water sports, competitive sports, and wilderness experiences.

This camper’s activities should be limited for the following reasons:

____________________________________________________________________________________

____________________________________________________________________________________

PHYSICIAN’S SIGNATURE:

_________________________________________________________________________________

ADDRESS: ______________________________________________________________________

DATE: ______________________ PHONE: _________________________________