Date
ADULT HEALTH HISTORY
Adult name
Address
Street
City
State
Name of family physician
Zip
Phone
INSURANCE INFORMATION
Is the participant covered by family medical/hospital insurance?
If so, indicate carrier or plan name
Yes No
Group #
HEALTH HISTORY
List any physical or behavioral conditions that may affect or limit full participation in Girl Scout activities:
Allergies (medication, food or other)
RESTRICTIONS – The following restrictions apply to this individual:
Does not eat red meat
Does not eat shellfish
Allergy to latex
Does not eat pork
Does not eat eggs Does not eat dairy products
Does not eat poultry Does not eat peanuts
Allergy to stinging insects
Other
Medications being taken (prescription and over-the-counter)
In case of an emergency, please notify:
Emergency contact name
Relationship
Phone-Day (
)
Evening (
)
Evening (
)
Emergency contact name
Relationship
Phone-Day (
)
Participant’s signature
Date
164