Girlscoutsnca.org

CAMP HEALTH HISTORY
This form to be completed by the parent/guardian. REQUIRED for ALL (Children and Adults; Day, Resident, Troop Core, and Family)
Name ____________________________________________________________________________________ Date of Birth _________________________________ Age ___________ Gender ____________ Height _____________ Weight _____________ Parent/Guardian _______________________________________________________________________________________________________ Address _____________________________________________ City _____________________________ State _______ Zip _______________ Parent’s Phone #s (home)(_____) ____________________(work)(_____) _____________________ (cell)(_____)_________________________ In Emergency Notify _______________________________________________________ Relationship __________________________________ Please list someone other than Parent/Guardian listed above Address _____________________________________________ City _____________________________ State _______ Zip _______________ Emergency Phone #s (home)(_____) _____________________ (work)(_____) _____________________ (cell)(_____)_____________________ Primary Care Physician _________________________________________________________ Phone (_____)_____________________________ Health Insurance Carrier ________________________________ contract number________________ Named Insured_____________________________ named Insured ______________________

RESTRICTIONS:
List any special medical or dietary regimen to be followed _________________________________________________
Is the camper allowed to participate in all camp activities? □ Yes □ No
If not, please list restricted activities ___________________________________________________________________

MEDICATIONS:
Is this person routinely taking medication including prescription, over-the-counter, vitamins, or alternative medication? □ Yes
If so, please list all _________________________________________________________________________________________
List any medication regularly taken by this person that he/she will not take while in attendance ______________________________

Check all medications that may be given by Health Supervisor, if needed (usually generic):
□ Cortizone/Anti-Itch Cream □ Benadryl topical □ Other __________________________________________________________
ALLERGIES: Is this person allergic to:
DISEASES:
□ Pol en* □ Plants* ____________________ □ Insects*____________________________ *Explain severity & treatment ______________________________________________________ □ Other ___________

HEALTH HISTORY: (Check if there is any history of.)
□ Asthma
□ Kidney Problems □ Musculoskeletal Disorders Please explain any checked items ___________________________________________________________________
Please list any problems related to menstruation ________________________________________________________
Has the participant been exposed to any communicable diseases within the past 30 days? □ Yes □ No
If so, please explain ________________________________________________________________________________

PAST MEDICAL TREATMENT/CONDITIONS: (list & give dates):
Operations/serious injuries __________________________________________________________________________
Hospitalizations ___________________________________________________________________________________
Other illness/disease _______________________________________________________________________________
CORRECTIVE APPLIANCE OR DEVICE:
Does this person use or wear a corrective appliance/device for mobility, vision, hearing, dental or have a prosthesis?
□ Yes
If so, please explain ____________________________________________________
BEHAVIORAL, EMOTIONAL, & MENTAL HEALTH:
Are there any behavioral, emotional, or mental health conditions that may require medication, treatment, restrictions,
or special consideration? □ Yes □ No
If so, please list___________________________________________ List any additional information about the attendee's behavioral, physical, emotional, or mental health that staff should be aware of:______________________________________________________________________________________ Is the camper able to change clothes, toilet, shower, and manage personal hygiene with minimal/no assistance? Is the camper able to follow directions and function as part of a group? □ Yes □ No

IMMUNIZATIONS/VACCINATIONS:
Is the campers exempt from immunizations due to religious/ medical reasons?
(If yes, a note will be required stating reason(s) for the exemption)
If not exempt, is the camper current on all recommended immunizations and vaccinations? □ Yes □ No Date of last Tetanus ______

This HEALTH HISTORY is accurate and complete to the best of my knowledge. The participant may engage in all activities
except as noted above. I give full permission for EMERGENCY MEDICAL TREATMENT and/or anesthesia to be
administered by qualified personnel as deemed necessary by the camp Health Supervisor or the Camp Director.
Parent / Guardian signature ______________________________________________________ Date _______________________

Source: http://girlscoutsnca.org/wp-content/uploads/2009HEALTHHISTORY_000.pdf