Pleasant Valley Pathfinder Club — Health & Medical Records Form

ATTENTION:

Please review the document and understand what you are signing. This is a legal document.

Please fill out the form as completely and accurately as possible (not just the required fields).

Make sure you have your immunization records, insurance information, and primary doctor's information on hand before you start!
Pathfinder Personal Information
Name *
Age *
Birth Date *

Month Day Year
Date
Home Phone (Primary Number)
Parent/Guardian Email Address *
example@example.com
Address *
City *
State *
Zip *
Sex *

Male Female
Pathfinder Club Name *
Health History | Past and Current

Please select all that apply

Health History

	None	Past	Now
Asthma
Bed Wetting
Constipation
Contact Lenses
Diabetes
Earache/Ear Trouble
Ear Tubes
Epilepsy
Fainting Spells
Frequent Diarrhea
Glasses
Hay Fever
Heart Trouble
Kidney Disease
Menstrual Problems
Rheumatic Fever
Severe Stomachaches
Sinus Trouble
Sleep Walking
Tuberculosis

Allergies/Allergic Reactions

Please fill out each section that the Pathfinder has had known allergic reactions with and tell what happened:
Medications
Bee Sting
Food
Poison Oak/Ivy
Other Allergies (list)
Additional Medical Information
Please list all serious illnesses or operations in the past five years. Please include the operation/illness, the date, and whether hospitalization happened or not.
Please list all medications currently being taken as well as the corresponding dates and reasons for each medication:
Any restriction of physical activity for medical reasons? If so, please explain.
Any other types of health concerns, which might be pertinent?
Any unusual behaviors? (nightmares, sleep talking, etc.)
Immunization History
Please select all applicable vaccines as well as their corresponding dates as best as possible.

Measles Vaccine (live) Date
German Measles (Rubella)   Date
DPT Series    Date   Booster:   Date
Polio OPV (Sabin)   Date   Booster:   Date
Tetanus Booster  Date
Turberculin Test   Date
Chicken Pox   Date
Mumps Vaccine (live)   Date
Oregon Residents: Does your child meet current Oregon State law for school attendance?

Medical Exemption Religious Exemption
Diet

Regular Diabetic Low Salt Low Fat/Cholesterol Vegan
Emergency Parental Contact Information
Parent/Guardian/Spouse *
Home Address
Home Phone (Primary Contact Number) *
Work Address
Work Phone (Secondary Contact Number)
Alternate Contact #1 (if parent is unavailable)
Name *
Address
Home Phone (Primary Contact Number) *
Work Phone (Secondary Contact Number)
Alternate Contact #2 (if parent is unavailable)
Name
Address
Home Phone (Primary Contact Number)
Work Phone (Secondary Contact Number)
Doctor to Consult in Case of Emergency
Name
Address
City
State
Zip
Phone
Medical Insurance
Do you have medical insurance? *
If you do have medical insurance, please provide your insurance number:
Insurance Name
PARENT'S AUTHORIZATIlON-required for those under 18 years of age or under 21 if still living at home.
This health history is correct so far as i know, and the child named above has permission to engage in all activities, except as noted herein by me. Exceptions (if any) . In the event I cannot be reached in an emergency, I hereby give permission to the medical provider selected by the adult leader in charge to hospitalize, secure proper anesthesia, or to order injections or surgery for my child. A photo copy of this shall be as valid as the original.
Signature of Parent or Guardian *

Clear
Date Signed *

Month Day Year
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Pathfinder Personal Information

Health History | Past and Current

Allergies/Allergic Reactions

Additional Medical Information

Immunization History

Emergency Parental Contact Information

Alternate Contact #1 (if parent is unavailable)

Alternate Contact #2 (if parent is unavailable)

Doctor to Consult in Case of Emergency

Medical Insurance