South Louisiana Council                                                                                                        Boy Scouts of America
Health History Form

Circle one:  Youth    Adult   Sibling                Bayou District                Pack 401

Name _________________________________________________ Date of Birth ______________________

Address _______________________________________________ City/State/Zip _____________________

Home Phone _____________________ Work _______________________ Cell/Pager __________________

Physicians Name________________________________________________ Phone ___________________

Health Insurance Company ________________________________________ Policy # _________________

Alternate Contact (not parents) _____________________________________ Phone ___________________

Check all items that apply, past or present.  Explain below any that are checked, use back if necessary
(  ) Allergies to medication, food, plant, insects _________________________________________________
(  ) Asthma        (  ) Fainting Spells        (  ) Convulsions/seizures        (  ) High blood pressure
(  ) Diabetic        (  ) Heart Trouble         (  ) Bleeding Disorder           (  ) Other significant medical problems

Do you have difficulty with (  ) Eyes, ears, nose, throat        (  ) Digestion                  (  ) Lungs
                                  (  ) Sleepwalking                (  ) Mental Illness        (  ) ADHD
Explain: ________________________________________________________________________________
(  ) Physical or behavioral condition that the staff should be aware __________________________________
(  ) Requires special equipment, or diet _______________________________________________________
(  ) restrictions from activity; explain _________________________________________________________

All medications presently taking: ____________________________________________________________
Cub Scouts are NOT ALLOWED to have any medications in their possession (including over the counter), except for Epi-Pens or Inhalers.  These medications must be reported to the camp health officer.
Camp is not responsible for administering medication.  Record medication to be taken at camp and person administering them: ______________________________________________________________________

Immunization:   (Give date of last inoculation)
        Tetanus toxoid ______        Polio ________        Measles ________                Rubella ________
        Diphtheria __________        Pertussis __________                Mumps ____________

Consent for Emergency Treatment (must be signed)
This health history is correct so far as I know and the person herein described, has permission to engage in all prescribed activities, except as noted by me.  I will not send my child if he has a Fever, any contagious condition, or for any reason that I do not consider him to be in good health.  In the event I cannot be reached in an emergency, I hereby give my permission to medical personnel to secure proper treatment including hospitalization, anesthesia, surgery or injection for my child/ward (or for myself).

Parent/Guardian signature _____________________________________        Relationship ______________

Printed Name of Signature above _____________________________         Date ____________________

Address ________________________________________        City/State/Zip _________________________
Required if different than above address
Home Phone _____________________________________Work Phone _____________________________
Beeper __________________        Cell Phone ______________________        Fax # _________________