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Cub Scouts Medical Parts_ab

Cub Scouts Medical Parts_ab

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Published by davidantis

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Published by: davidantis on Jun 19, 2012
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06/19/2012

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High-adventure base participants:
Expedition/crew No.: __________________________________________________or sta position: _______________________________________________________
680-0012011 PrintingRev. 2/2011
   F  u   l   l  n  a  m  e  :_________________________________   D   O   B  :______________   A   l   l  e  r  g   i  e  s  :__________________   E  m  e  r  g  e  n  c  y  c  o  n   t  a  c   t   N  o .  :___________________
Annual BSA Health and Medical Record
Part A
GENERAL INFORMATION
Name ___________________________________________________________________ Date obirth ________________________________ Age _____________ Male Female Address _________________________________________________________________________________________________________________________ Grade completed (youth only) __________City _____________________________________________________________________ State ____________ Zip ____________________________ Phone No. ________________________________Unit leader ______________________________________________________ Council name/No. ___________________________________________ Unit No. ___________________Social Security No.
(optional; may be required by medical acilities or treatment)
_______________________Religious preerence ______________________________Health/accident insurance company __________________________________________________________ Policy No. ________________________________________________________
 ATTACH A PHOTOCOPY OF BOTH SIDES OF INSURANCE CARD. IF FAMILY HAS NO MEDICAL INSURANCE, STATE “NONE.”
In case o emergency, notiy:Name _________________________________________________________________________________ Relationship _____________________________________________________________ Address _________________________________________________________________________________________________________________________________________________________________Home phone _________________________________________ Business phone _______________________________ Cell phone ___________________________________________ Alternate contact _________________________________________________________________________ Alternate’s phone ___________________________________________________
HEALTH HISTORY
 Are you now, or have you ever been treated or any o the ollowing:
 Allergies or Reaction to: YesNoConditionExplain
Medication ____________________________________Food, Plants, or Insect Bites __________________________________________________________________
Immunizations:
The ollowing are recommended by the BSA.
Tetanus immunization is required and must
have been received within the last 10 years.
Ifhad disease, put “D” and the year. If immunized,check the box and the year received.
Yes No Date
 
Tetanus
________________________Pertussis _______________________Diphtheria ______________________Measles ________________________Mumps _________________________Rubella _________________________Polio ____________________________Chicken pox____________________Hepatitis A _____________________Hepatitis B _____________________Inuenza _______________________Other (i.e., HIB) ________________
 
Exemption to immunizations claimed(orm required). Asthma Last attack: ____________Diabetes Last HbA1c: ____________
Hypertension (high blood pressure)
Heart disease (e.g., CHF, CAD, MI)Stroke/TIALung/respiratory diseaseEar/sinus problemsMuscular/skeletal conditionMenstrual problems (women only)Psychiatric/psychological andemotional difcultiesBehavioral disorders (e.g., ADD, ADHD, Asperger syndrome, autism)Bleeding disordersFainting spellsThyroid diseaseKidney diseaseSickle cell diseaseSeizures Last seizure: ____________Sleep disorders (e.g., sleep apnea)Use CPAP: YesNo Abdominal/digestive problemsSurgerySerious injuryOther
MEDICATIONS
List all medications currently used. (I additional space is needed, please photocopythis part o the health orm.) Inhalers and EpiPen inormation must be included, eveni they are or occasional or emergency use only.
Medication _____________________________Strength ________ Frequency ____________ Approximate date started ________________Reason or medication ___________________________________________________________Medication _____________________________Strength ________ Frequency ____________ Approximate date started ________________Reason or medication ___________________________________________________________Medication _____________________________Strength ________ Frequency ____________ Approximate date started ________________Reason or medication ___________________________________________________________Medication _____________________________Strength ________ Frequency ____________ Approximate date started ________________Reason or medication ___________________________________________________________Medication _____________________________Strength ________ Frequency ____________ Approximate date started ________________Reason or medication ___________________________________________________________Medication _____________________________Strength ________ Frequency ____________ Approximate date started ________________Reason or medication ___________________________________________________________
 Administration o the above medications is approved by (i required by your state):
________________________/ _______________________
Parent/guardian signature and/or MD/DO, NP, or PA signature
Be sure to bring medications in sufcient quantities and the original containers. Make sure that they are
NOT
expired, including inhalers and EpiPens. You
SHOULD NOT STOP
taking any maintenance medication.
(For more information about immunizations,as well as the immunization exemption form,see Scouting Safely on Scouting.org.)

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