Microsoft word - adult health history and medical exam form

ADULT HEALTH HISTORY AND MEDICAL EXAMINATION FORM Health History: An annual updated record of an adult’s past and present health status completed by the adult. A health history is required for physical y demanding activities (i.e., horseback riding, canoeing). Health History must be completed by the adult and the Health Information Privacy Statement must be signed. Medical Examination: A medical examination is completed for travel lasting more than three nights or high-risk activities (i.e., rappel ing, white-water rafting). The examination is completed by a licensed physician, nurse practitioner, physician’s assistant or registered nurse within the preceding 24 months unless a health issue is present. The adult must sign the Health Information Privacy Statement. Please type or write clearly and legibly. Name of Adult: (Last, First, Middle Initial) Emergency Contact Information (another adult): Health Insurance Information (Family insurance is primary insurance in case of accident or illness, Girl Scout insurance is secondary.) Check all that apply and explain in detail checked answers: Please explain in detail all checked answers marked above: Allergies: Please list al al ergies, the type of reaction and its severity, treatment and date of last reaction. Include al ergies to medications, food, bees, animals, plants, etc. *Anaphylaxis is a severe al ergic reaction marked by swel ing of the throat or tongue, hives, and trouble breathing. Do you carry an EpiPen? Medical Conditions (including any precautions or restrictions on activities) Medications: List any medications you are currently taken (or have taken in the recent past) including dosage schedule and specific instructions for use. Over-the-Counter Medications: In case of accident or injury, please mark al that apply: Do you have a Special Medical or Dietary Regiment to be followed? Yes Have you ever had any adverse reactions to general anesthetics? Any other information not covered in this form that is important that advisors for this trip know: Medical Examination – Must be completed in detail. (This section is to be completed by a physician after the review of health history with adult. Adult must complete all the information of the Health History to the best of their knowledge and sign before meeting with licensed professional.) Record of Immunization – Must be completed in detail. Personal and religious beliefs dictate against immunizations: If yes, please complete the Exemption for Physical Examination and Immunization. Not required immunizations, but recommended Height: Weight: B. P.: / Hearing: R L Eyes: With Glasses R 20/ Code: S = Satisfactory NS = Not Satisfactory NE = Not Examined *Girls should have this test if she had not had it since entering puberty. Licensed Physician Name: (Last, First, Middle Initial) This person is in satisfactory condition and may engage in al usual activities, including physical y demanding activities except as noted. Signature of Licensed Physician: HEALTH INFORMATION PRIVACY STATEMENT The Health History and Medical Examination Form for Adults is for health care concerns at the specified event only. Al records wil be handled by staff/volunteers whose job includes processing or using this information for the benefit of the participant. Al medical records wil 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. Access to the information wil 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, bil ing or insurance purposes. This Health History and Medical Examination Form for Adults is complete and accurate. Signature of Adult Participant:

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