American heritage girls

American Heritage Girls, Inc.
Health and Medical History Form
This form is valid for 12 months
Member Name: _________________________________________ Troop # _________________ _____/_____/_____ Age: ________ Weight___________ Custodial parent/guardian: __________________________________________________________ Home address: ____________________________________________________________________ City: _____________________________________ State: ________ Zip Code:___________ Home phone: _________________________ Work/cell phone: _____________________________ If parent/guardian above cannot be reached in the event of an emergency, notify: Name:___________________________________________________________________________ Relationship:__________________________________ Name:___________________________________________________________________________ Relationship:__________________________________  Member does not have health care coverage at this time  Member has health care coverage as listed below Insurance Provider ________________________________________________________________ Address _______________________________________________ Phone # __________________ Policy Holder _____________________________________ Policy #_______________________ Group # __________________________________________ Effective Date __________________ Primary Care Physician _____________________________________________________________ Physician’s address:_________________________________________ Phone #: ________________ Dentist’s name:____________________________________________________________________ Dentist’s Address:__________________________________________ Phone #:________________ Preferred Hospital:_________________________________________________________________ ALLERGIES:
Please list all known allergies including those to medications, food and environment. If none known, please write “none known”. Attach additional page to this form if needed. Allergy to: Normal reaction and management of the reaction GENERAL HEALTH INFORMATION:
(Please circle all items that apply, past or present, to your health history. Explain all “Yes” answers.)
Explain any “YES” answers:
__________________________________________________________________________________________

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IMMUNIZATIONS:

Year primary series completed
DPT_______________________ __________________ Oral Polio___________________ __________________ Measles____________________ __________________ Rubella_____________________ __________________ Mumps_____________________ __________________ Tetanus Shot_________________ __________________ Year last given:________ Result:_________
Medications
Please include all medications the participant is currently taking. If these medications need to be administered during an AHG event,
the Request for Medication Administration form must be completed.
Medicine Name
Reason taking/instructions
Date of last physical examination:___________________________
Over the Counter, As Needed Medications
The following are OTC medications that may be available at AHG functions on an as-needed basis. Please consult with your
physician and indicate which medications the participant may receive.

OTC drug name
Indications
Permission
Comments
(generic may be used.)
I give permission for the medication indicated above to be given to my child (or self if an adult participant) if needed. Signature of Parent/Guardian or Adult______________________________________ Date _________________
Use this space to provide any additional information about the participant’s behavior and physical, emotional or mental health needs pertinent to his/her participation in the American Heritage Girls program. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ I give permission for full participation in American Heritage Girls programs, subject to limitations noted herein. This health history is correct and complete, as far as I know. I hereby give permission for AHG leadership to administer prescribed and noted over the counter medications.
In case of emergency, I understand every effort will be made to contact me (if participant is an adult, my spouse or next of kin).
In the event that I cannot be reached, I hereby give my permission to the licensed health-care provider selected by the adult leader
in charge to secure proper treatment, including related transportation, hospitalization, anesthesia, surgery, or injections of medication for my child (or for me, if member is an adult), except as noted. I agree to the release of records necessary for treatment. Notes: _________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Date _________Signature of parent/guardian or adult ____________________________________________________________ I do NOT give my consent for medical treatment of my child (or for me, if member is an adult). In the event of illness or injury requiring treatment, I wish AHG leadership to take NO action beyond basic first-aid measures. Date ________ Signature of parent/guardian or adult _____________________________________________________________

Source: http://wccn.cc/images/B/GirlHealthMedicalHistoryForm.pdf