Girl scouts health history and medical examination form for adults

Girl Scouts of Northern Illinois
Health History 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.


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:
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:
 Diseases of the Ears or Ear Infections  Hypertension/Abnormal Blood Pressure  Eating Disorders (Anorexia, Bulimia, etc.)  Had surgery or hospitalized in the last 5 years Please explain in detail all checked answers marked above:

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
*Anaphylaxis is a severe allergic reaction marked by swelling of the throat or tongue, hives, and trouble breathing. Do you carry an Epipen? 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 all that apply:
 Tylenol/Acetaminophen
Special considerations or notes regarding
over-the-counter medications:

Do you have a Special Medical or Dietary Regiment to be followed? Yes
Have you ever had any adverse reactions to general anesthetics?
Additional information that is important for other advisors on this trip to know about:
HEALTH INFORMATION PRIVACY STATEMENT
The Adult Health History 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 Form is complete and accurate.
Signature of Adult Participant:

Source: http://www.girlscoutsni.org/forms/GSNI_Adult_Health_History_FY2013.pdf