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Girl scouts health history and medical examination form for minors

Girl Scouts of Historic Georgia
2013 Summer Camp Health History and Medical Examination Form for Girls
Please check: Concharty Low Martha Johnston Okitayakani Tanglewood

Program Name:


Health History:
The more complete information you provide, the better we are able to work with your child to ensure she
Medical Examination: A medical examination is completed for trips lasting more than three nights. The examination is
completed by a licensed physician, nurse practitioner, physician’s assistant or registered nurse within the preceding 24 months Please type or write clearly and legibly. Name of Girl: (Last, First, Middle Initial)
Date of Birth: (XX/XX/XXXX)
Address:
Parent or Guardian:
Alternate Phone:
Parent or Guardian:
Alternate Phone:
Emergency Contact Information (parent/guardian):
Emergency Contact:
Relationship:
Alternate Phone:

Health Insurance Information
(Family insurance is primary insurance in case of accident or il ness, 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 on a separate sheet and attach it to this form:

 Eating Disorders (Anorexia, Bulimia, etc.)  Had surgery or hospitalized in the last 5 years p.1- 2013 Summer Camp Health History Form/Girls
Girl Name:


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
Does your daughter suffer from Anaphylaxis? Yes *Anaphylaxis is a severe al ergic reaction marked by swelling of the throat or tongue, hives, and trouble breathing. Medical Conditions (including any precautions or restrictions on activities)
Name of Condition

Medications: List any medications she is currently taken (or has taken in the recent past) including dosage schedule and
specific instructions for use. Also, please indicate (Yes/No) if she is al owed to take the medication on her own or if she should be monitored by an advisor. This would include any type of birth control. Medication
Dosage Schedule
Specific Instructions
Self-Medicate?
(Yes/No)

Over-the-Counter Medications: My daughter has permission to take over-the-counter medications in case of accident or injury.
Please check al that she has permission to take: Special considerations or notes
regarding over-the-counter medications:

Does your child 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:
p.2- 2013 Summer Camp Health History Form/Girls Girl Name:
(This section is to be completed by a physician after the review of health history with parent/guardian. Parent/Guardian must
complete all the information of the Health History to the best of their knowledge and sign before meeting with licensed professional.)

Medical Examination – Must be completed in detail.
Code: S = Satisfactory NS = Not Satisfactory NE = Not Examined *Girls should have this test if she had not had it since entering puberty. Record of Immunization – Must be completed in detail. Or please attach an official record of immunization from your doctor.
Not required immunizations, but recommended Personal and religious beliefs dictate against immunizations: Physician Information
Licensed Physician Name: (Last, First, Middle Initial)
Phone Number:
Address:
This person is in satisfactory condition and may engage in all usual activities, including physical y demanding activities except
Signature of Licensed Physician:

State License Number:

HEALTH INFORMATION PRIVACY STATEMENT

The GSHG Summer Camp Health History and Medical Examination Form for Girls 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. All 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 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. I understand that effort wil be made to reach me in case of an emergency. , the parent/legal guardian of the above named camper authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed by a licensed physician/emergency care provider or hospital and/or camp healthcare supervisor when deemed immediately necessary or advisable by the physician/emergency care provider or hospital and/or camp healthcare supervisor to safeguard my camper’s health. I waive my right of informed consent to such treatment.
This GSHG Health History and Medical Examination Form for Girls is complete and accurate. My daughter has permission to engage
in all prescribed activities, except as noted by me and the examining physician.
Signature of Parent/Guardian:
p.3- 2013 Summer Camp Health History Form/Girls

Source: https://www.gshg.org/Volunteer-Resources/Volunteer%20Documents/GSHG%20Summer%20Camp%20Girl%20Health%20Form.pdf

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