Trail Life Troop 9871Health and Medical Record
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Your Age
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Troop Leader
Emergency Contacts
Emergency Contact #1
First Name
Last Name
Emergency Contact #1 Relationship
Emergency Contact #1 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2
First Name
Last Name
Emergency Contact #2 Relationship
Emergency Contact #2 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Health Insurance Information
Participant does not have health insurance
Participant does have health insurance, and is listed below
Health/accident insurance company name
Health Insurance Policy Number
Health Insurance Policy Holder Name
Group Number
Effective Date
-
Month
-
Day
Year
Date
Upload copy of both sides of insurance card
Browse Files
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Primary Care Physician Name
Physician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dentist Name
First Name
Last Name
Dentist Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Hospital Name
Participants Name
First Name
Last Name
Signature
Today's Date
-
Month
-
Day
Year
Date
Allergy to #1
Normal Reaction and management of the reaction #1
Allergy to #2
Normal Reaction and management of the reaction #2
Allergy to #3
Normal Reaction and management of the reaction #3
Asthma
Yes
No
Asthma Last Attach
Asthma explain more if needed
Diabetes
Yes
No
Diabetes explain more if needed
Hypertension (high blood pressure)
Yes
No
Hypertension (high blood pressure) explain more if needed
Heart Disease / Heart Attach / chest pain / heart murmor
Yes
No
Heart Disease / Heart Attach / chest pain / heart murmor explain more if needed
Stroke / TIA
Yes
No
Stroke / TIA explain more if needed
Lung/Respiratory Disease
Yes
No
Lung/Respiratory Disease explain more if needed
Ear / Sinus problems
Yes
No
Ear / Sinus problems explain more if needed
Muscular/Skeletal condition
Yes
No
Muscular/Skeletal condition explain more if needed
Psychiatric / psychological and emotional difficulties
Yes
No
Psychiatric / psychological and emotional difficulties explain more if needed
behavioral/neurological disorders
Yes
No
behavioral/neurological disorders explain more if needed
Bleeding disorders
Yes
No
Bleeding disorders explain more if needed
Fainting spells
Yes
No
Fainting spells explain more if needed
Thyroid disease
Yes
No
Thyroid disease explain more if needed
Kidney Disease
Yes
No
Kidney Disease explain more if needed
Sickle cell disease
Yes
No
Sickle cell disease explain more if needed
Seizures
Yes
No
Last Seizure
Seizures explain more if necessary
Sleep disorders
Yes
No
Sleep disorders explain more if necessary
Use CPAP?
Abdominal Digestive Problems
Yes
No
Abdominal Digestive Problems explain more if necessary
Surgery
Yes
No
Surgery explain more if necesary
Last Surgery MM/YY
Serious Injury
Yes
No
Serious Injury explain more if necessary
Excessive Fatigue or shortness of breath with exercise
Yes
No
Excessive Fatigue or shortness of breath with exercise explain more if necessary
Other
Yes
No
Other explain more if necessary
Immunizations
Rows
Yes I've had immunization
No I haven'd had immunization
Date of Immunization
Yes I've had disease
No I havent had disease
Date of Disease
tetnus
Pertussis
Diptheria
Measles
Mumps
Rubella
Polio
Chicken Pox
Hep A
Heb B
Meningitis
Influenza
Other
Exception to immunizations
Medication #1Medications
Rows
Medications
Strength
Frequency
Approx date started
Reason
Medication #1
Medication #2
Medication #3
Medication #4
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