Girl Scouts of Central Texas

12012 Park Thirty-five Circle, Austin, TX 78753

(512) 453-7391(800) 733-0011

GIRL AND ADULT HEALTH HISTORY FORM

Name: Date of Birth: Age:

Address: Phone/Area Code:

Parent/Guardian Name:

Home Address: Phone/Area Code:

Business Address: Phone/Area Code:

Emergency Contact: Relationship:

Emergency Address: Phone/Area Code:

Family Physician: Phone/Area Code:

Family Medical Insurance Carrier: Policy/Group #:

Part I: Illness and Injuries (Check those that apply and give appropriate dates):

Ear Infection Bleeding/clotting Disorder Hypertension Asthma Heart Defect/Disease Muscular-skeletal Disorder

Seizures Diabetes Other (explain)

Date of last health examination:
Were any complicating medical problems noted in last health exam?

Is participant currently under the care of a physician or psychologist?

Since last health exam has participant had:
a serious injury requiring medical attention? illness lasting more than 5 days?
any prescribed or over-the-counter medication? a surgical operation or fracture?
treatment in a hospital or emergency room? restrictions concerning physical activity?
any exposure to a contagious disease?
Please explain any “Yes” answers to the above questions, including dates:

Part II: Allergies (Check those that apply and specify nature of allergic reaction): None

Animals Hay Fever Pollen Food Plants

Medicine/drugs Insect Stings Other (Specify)

Part III: Other Health Conditions (Check those applying):

Bed Wetting Emotional Disturbances Constipation Fainting Menstruation Hearing Impairment

Motion Sickness Sickle Cell trait or disease Nosebleeds Special Dietary regimen Sleep Disturbances

Wears glasses/contact lenses Other(Specify)

Part IV: Immunization History: Do NOT write “Current” or “Up to date” in the blanks.

ImmunizationYear of Last BoosterImmunizationYear of Last Booster

D.P.T. Rubella
Diphtheria Oral Polio
Pertussis (Whooping Cough) HBPV
Tetanus Tuberculin test (most recent) result
T.B. Mumps
Measles Other

Please explain any items that are checked. Indicate any information useful to the adult in charge in relation to any of these health conditions. Also indicate any activities to be encouraged or restricted.

I know of no reason(s), other than the information indicated on this form, why my child should not participate in prescribed activities except as noted.

Signature of Parent/Guardian: Date:

This health history is correct and I am able to engage in all prescribed activities except as noted:

Signature of Adult: Date: