Girl scouts health history and medical examination form for adults
Girl Scouts of Northern Illinois
Health History Form for Adults
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:
Spouse (if applicable):
Emergency Contact Information:
Health Insurance Information
(Family insurance is primary insurance in case of accident or illness, Girl Scout insurance
Policy Holder's Name:
Insurance Company Name:
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:
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.
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?
(including any precautions or restrictions on activities)
Name of Condition
: List any medications currently taken (or has taken in the recent past) including dosage schedule
and specific instructions for use.
In case of accident or injury. Please check all that apply:
Special considerations or notes regarding
Do you have a Special Medical or Dietary Regiment to be followed?
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:
18.02.2011 Cheeses of t Saint Loup / Trinity Buche Delice de Bourgogne Pont L’Eveque 1kg 1.8kg 1.4kg white mould - goat milkWestern-Loire, FranceThis decadent triple cream is incredibly rich, delicate white penicillin mould rind, this lushness of it’s pastures. The aroma of yellowish-white with a soft-delicate
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