GIRL HEALTH HISTORY RECORD. This health history is to be completed and signed by Diabetes. Other (specify) Date of last health examination: …
|GIRL HEALTH HISTORY RECORD
This health history is to be completed and signed by parents/guardians
| | |
|Name | |Date of | |Age| |
| | |Birth | | | |
|Address | |Troop No| |
|Parent/Guardi| |Area Code | |
|an | |Phone Number | |
|Home | |
|Address | |
|Business | |Area Code | |
|Address | |Phone Number | |
|In Emergency | | | |
|Notify |Relationship | | |
|Name |
| | |
|Address | |Area Code | |
| | |Phone Number | |
|Name of family | |Area Code | |
|physician | |Phone Number | |
|Family | |Policy or Group | |
|medical/hospital | |No | |
|insurance carrier:| | | |
|Part I: Illnesses and Injuries check those | |
|that apply and give appropriate dates | |
|Chronic or | |
|Recurring Illness | |
|Ear Infection |Bleeding/Clotting |Hyperten-si|Asthma | |
| |Disorders |on | | |
|Hear
Defect/ |Musculoskeletal |Seizures |Diabetes |Other | |
|Disease |Disorders | | |specify | |
|Date of last | |
|health | |
|examination: | |
|Were any complicating medical problems | |
|noted in last health examination? | |
|Is participant currently under the | |
|care of a physician or psychologist? | |
|Since last health exam, | |
|has participant had: | |
|A serious injury requiring | |An illness lasting more | | |
|medical attention? | |than five days? | | |
|Any prescribed or
| |A surgical operation or | | |
|over-the-counter medication?| |fracture? | | |
|Treatment in a hospital or | |Any restrictions concerning| | |
|emergency room? | |physical activities? | | |
|Any exposure to a contagious| | | | |
|disease? | | | | |
|Please explain any yes answers to the above | |
|questions Include dates: | |
| |
| |
| |
|Part II: Allergies Check those that apply|Part IV: Immunization History |
|and specify nature of allergic reaction | |
|Animals |
|Hay Fever | | | |
|Part III: Other health conditions Check |TB | | | | |
|those that apply | | | | | |
| |Measles | | | | |
|Bed wetting |Emotional Disturbances|Mumps | | | | |
|Constipation |Fainting |Rubella German | | | | |
| | |measles | | | | |
|Menstrual Cramps |Hearing Impairment |Oral polio | | | | |
|Motion sickness |Sickle cell trait or |Hib | | | | |
| |disease | | | | | |
|Nosebleeds |Special dietary |Hepatitis B | | | | |
| |regimen | | | | | |
|Sleep disturbances |Wears glasses or |Tuberculin test | | | | | |
| |contacts |most recent | |
| | | |
|Other | |Other | |
|specify | | | |
|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 |
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|This health history is complete and accurate I know of no reasons, other than the |
|information on this form, why my daughter should not participate in prescribed |
|activities except as noted |
|Signature of | |Dat| |
|parent/guardian | |e | |
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Source:diabeticretinopathy.org.uk
