Fillable Bsa Health Form PDF Details

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QuestionAnswer
Form NameFillable Bsa Health Form
Form Length4 pages
Fillable?Yes
Fillable fields235
Avg. time to fill out24 min 2 sec
Other namesbsa medical form pdf, bsa health forms, bsa health form 2020 pdf, bsa fillable medical pdf

Form Preview Example

Part A: Informed Consent, Release Agreement, and Authorization

A

Full name: ____________________________________________

Date of birth:__________________________________________

High-adventure base participants:

Expedition/crew No.:_ _______________________________________________

or staff position:___________________________________________________

Informed Consent, Release Agreement, and Authorization

I understand that participation in Scouting activities involves the risk of personal injury, including death, due to the physical, mental, and emotional challenges in the activities offered. Information about those activities may be obtained from the venue, activity coordinators, or your local council. I also understand that participation in these activities is entirely voluntary and requires participants to follow instructions and abide by all applicable rules and the standards of conduct.

In case of an emergency involving me or my child, I understand that efforts will be made to contact the individual listed as the emergency contact person by the medical provider and/or adult leader. In the event that this person cannot be reached, permission is hereby given to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for me or my child. Medical providers are authorized to disclose protected health information to the adult in charge, camp medical staff, camp management, and/or any physician or health-care provider involved in providing medical care to the participant. Protected Health Information/Confidential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R. §§160.103, 164.501, etc. seq., as amended from time to time, includes examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities.

(If applicable) I have carefully considered the risk involved and hereby give my informed consent for my child to participate in all activities offered in the program. I further authorize the sharing of the information on this form with any BSA volunteers or professionals who need to know of medical conditions that may require special consideration in conducting Scouting activities.

With appreciation of the dangers and risks associated with programs and activities, on my own behalf and/or on behalf of my child, I hereby fully and completely release and waive any and all claims for personal injury, death, or loss that may arise against the Boy Scouts of America, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with any program or activity.

I also hereby assign and grant to the local council and the Boy Scouts of America, as well as their authorized representatives, the right and permission to use and publish the photographs/film/ videotapes/electronic representations and/or sound recordings made of me or my child at all Scouting activities, and I hereby release the Boy Scouts of America, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all liability from such use and publication. I further authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/film/videotapes/electronic representations and/or sound recordings without limitation at the discretion of the BSA, and I specifically waive any right to any compensation I may have for any of the foregoing.

Every person who furnishes any BB device to any minor, without the express or implied permission of the parent or legal guardian of the minor, is guilty of a misdemeanor. (California Penal Code

Section 19915[a]) My signature below on this form indicates my permission.

I give permission for my child to use a BB device. (Note: Not all events will include BB devices.)

Checking this box indicates you DO NOT want your child to use a BB device.

NOTE: Due to the nature of programs and activities, the Boy Scouts of America and local councils cannot continually monitor compliance of program participants or any limitations imposed upon them by parents or medical providers. However, so that leaders can be as familiar as possible with any limitations, list any restrictions imposed on a child participant in connection with programs or activities below.

List participant restrictions, if any:None

________________________________________________________

I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in any event or activity. If I am participating at Philmont Scout Ranch, Philmont Training Center, Northern Tier, Sea Base, or the Summit Bechtel Reserve, I have also read and understand the supplemental risk advisories, including height and weight requirements and restrictions, and understand that the participant will not be allowed to participate in applicable high-adventure programs if those requirements are not met. The participant has permission to engage in all high-adventure activities described, except as specifically noted by me or the health-care provider. If the participant is under the age of 18, a parent or guardian’s signature is required.

Participant’s signature:_____________________________________________________________________________________________ Date:_ ______________________________

Parent/guardian signature for youth:___________________________________________________________________________________ Date:_ ______________________________

(If participant is under the age of 18)

Complete this section for youth participants only:

Adults Authorized to Take Youth to and From Events:

You must designate at least one adult. Please include a phone number.

Name: __________________________________________________________________

Name: __________________________________________________________________

Phone: __________________________________________________________________

Phone: __________________________________________________________________

Adults NOT Authorized to Take Youth to and From Events:

Name: __________________________________________________________________

Name: __________________________________________________________________

Phone: __________________________________________________________________

Phone: __________________________________________________________________

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Part B1: General Information/Health History

Full name: ____________________________________________

Date of birth:__________________________________________

B1

High-adventure base participants:

Expedition/crew No.:_ _______________________________________________

or staff position:___________________________________________________

Age:_ ____________________________ Gender:_ __________________________ Height (inches):_ ___________________________ Weight (lbs.):_____________________________

Address:__________________________________________________________________________________________________________________________________________

City:_ ___________________________________________ State:_____________________________ ZIP code:_ __________________ Phone:_______________________________

Unit leader:_____________________________________________________________________________ Unit leader’s mobile #:_________________________________________

Council Name/No.:________________________________________________________________________________________________________Unit No.:_____________________

Health/Accident Insurance Company:_ ________________________________________________________ Policy No.:____________________________________________________

Please attach a photocopy of both sides of the insurance card. If you do not have medical insurance, enter “none” above.

In case of emergency, notify the person below:

Name:_______________________________________________________________________________Relationship:____________________________________________________

Address: _________________________________________________________________ Home phone:_ _________________________ Other phone:_ _________________________

Alternate contact name:__________________________________________________________________ Alternate’s phone:_______________________________________________

Health History

Do you currently have or have you ever been treated for any of the following?

Yes

No

Condition

 

Explain

 

 

Diabetes

Last HbA1c percentage and date:

Insulin pump: Yes £ No £

 

 

 

 

 

 

 

Hypertension (high blood pressure)

 

 

 

 

 

 

 

 

 

Adult or congenital heart disease/heart attack/chest pain (angina)/

 

 

 

 

heart murmur/coronary artery disease. Any heart surgery or

 

 

 

 

procedure. Explain all “yes” answers.

 

 

 

 

 

 

 

 

 

Family history of heart disease or any sudden heart-related

 

 

 

 

death of a family member before age 50.

 

 

 

 

 

 

 

 

 

Stroke/TIA

 

 

 

 

 

 

 

 

 

Asthma/reactive airway disease

Last attack date:

 

 

 

 

 

 

 

 

Lung/respiratory disease

 

 

 

 

 

 

 

 

 

COPD

 

 

 

 

 

 

 

 

 

Ear/eyes/nose/sinus problems

 

 

 

 

 

 

 

 

 

Muscular/skeletal condition/muscle or bone issues

 

 

 

 

 

 

 

 

 

Head injury/concussion/TBI

 

 

 

 

 

 

 

 

 

Altitude sickness

 

 

 

 

 

 

 

 

 

Psychiatric/psychological or emotional difficulties

 

 

 

 

 

 

 

 

 

Neurological/behavioral disorders

 

 

 

 

 

 

 

 

 

Blood disorders/sickle cell disease

 

 

 

 

 

 

 

 

 

Fainting spells and dizziness

 

 

 

 

 

 

 

 

 

Kidney disease

 

 

 

 

 

 

 

 

 

Seizures or epilepsy

Last seizure date:

 

 

 

 

 

 

 

 

Abdominal/stomach/digestive problems

 

 

 

 

 

 

 

 

 

Thyroid disease

 

 

 

 

 

 

 

 

 

Skin issues

 

 

 

 

 

 

 

 

 

Obstructive sleep apnea/sleep disorders

CPAP: Yes £ No £

 

 

 

 

 

 

 

 

List all surgeries and hospitalizations

Last surgery date:

 

 

 

 

 

 

 

 

List any other medical conditions not covered above

 

 

 

 

 

 

 

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Part B2: General Information/Health History

Full name: ____________________________________________

Date of birth:__________________________________________

B2

High-adventure base participants:

Expedition/crew No.:_ _______________________________________________

or staff position:___________________________________________________

Allergies/Medications

DO YOU USE AN EPINEPHRINEYES NO

AUTOINJECTOR? Exp. date (if yes) ___________________________

Are you allergic to or do you have any adverse reaction to any of the following?

Yes

No

Allergies or Reactions

Explain

 

 

 

 

Medication

Food

DO YOU USE AN ASTHMA RESCUEYES NO

INHALER? Exp. date (if yes) ___________________________________

Yes

No

Allergies or Reactions

Explain

 

 

 

 

 

 

Plants

 

 

 

 

 

 

 

Insect bites/stings

 

 

 

 

 

List all medications currently used, including any over-the-counter medications.

Check here if no medications are routinely taken.

If additional space is needed, please list on a separate sheet and attach.

Medication

Dose

Frequency

Reason

YES NO

Non-prescription medication administration is authorized with these exceptions:_________________________________________________________________

Administration of the above medications is approved for youth by:

_______________________________________________________________________ /________________________________________________________________________

Parent/guardian signature

MD/DO, NP, or PA signature (if your state requires signature)

Bring enough medications in sufficient quantities and in the original containers. Make sure that they are NOT expired, including inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance medication unless instructed to do so by your doctor.

Immunization

The following immunizations are recommended. Tetanus immunization is required and must have been received within the last 10 years. If you had the disease, check the disease column and list the date. If immunized, check yes and provide the year received.

Yes

No

Had Disease

Immunization

Date(s)

 

 

 

 

 

Tetanus

Pertussis

Diphtheria

Measles/mumps/rubella

Polio

Chicken Pox

Hepatitis A

Hepatitis B

Meningitis

Influenza

Other (i.e., HIB)

Exemption to immunizations (form required)

Please list any additional information about your medical history:

_________________________________________

_________________________________________

_________________________________________

_________________________________________

DO NOT WRITE IN THIS BOX.

Review for camp or special activity.

Reviewed by:_ ___________________________________________

Date:_ _________________________________________________

Further approval required: YesNo

Reason:_ _______________________________________________

Approved by:____________________________________________

Date:_ _________________________________________________

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Part C: Pre-Participation Physical

This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants.

C

Full name: ____________________________________________

Date of birth:__________________________________________

High-adventure base participants:

Expedition/crew No.:_ _______________________________________________

or staff position:___________________________________________________

You are being asked to certify that this individual has no contraindication for participation in a Scouting experience. For individuals who will be attending a high-adventure program, including one of the national high-adventure bases, please refer to the supplemental information on the following pages or the form provided by your patient. You can also visit www.scouting.org/health-and-safety/ahmr to view this information online.

Please fill in the following information:

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

Explain

 

 

Medical restrictions to participate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

Allergies or Reactions

 

Explain

 

 

Yes

 

No

 

 

Allergies or Reactions

 

 

Explain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Plants

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Food

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insect bites/stings

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Height (inches)

 

 

 

Weight (lbs.)

 

BMI

 

 

 

 

Blood Pressure

 

 

Pulse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Normal

Abnormal

 

Explain Abnormalities

Examiner’s Certification

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I certify that I have reviewed the health history and examined this person and find

no contraindications for

 

 

 

 

 

 

 

 

 

 

 

 

 

Eyes

 

 

 

 

 

 

 

 

 

 

 

participation in a Scouting experience. This participant (with noted restrictions):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

True

 

False

 

 

 

Explain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ears/nose/throat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Meets height/weight requirements.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lungs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has no uncontrolled heart disease, lung disease, or hypertension.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has not had an orthopedic injury, musculoskeletal problems, or orthopedic

Heart

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

surgery in the last six months or possesses a letter of clearance from his or her

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

orthopedic surgeon or treating physician.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has no uncontrolled psychiatric disorders.

 

 

Abdomen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has had no seizures in the last year.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Genitalia/hernia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does not have poorly controlled diabetes.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If planning to scuba dive, does not have diabetes, asthma, or seizures.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Musculoskeletal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Examiner’s signature:_ _______________________________________ Date: _ _______________

Neurological

 

 

 

 

 

 

 

 

 

Examiner’s printed name:_ _________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:________________________________________________________________________

Skin issues

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:_ ______________________________________State:_ ______________ ZIP code:_ _________

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office phone:____________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Height/Weight Restrictions

If you exceed the maximum weight for height as explained in the following chart and your planned high-adventure activity will take you more than 30 minutes away from an emergency vehicle/ accessible roadway, you may not be allowed to participate.

Maximum weight for height:

Height (inches)

Max. Weight

 

Height (inches)

Max. Weight

Height (inches)

Max. Weight

 

Height (inches)

Max. Weight

 

 

 

 

 

 

 

 

 

 

 

60

166

65

195

 

70

226

75

260

 

 

 

 

 

 

 

 

 

 

 

61

172

66

201

 

71

233

76

267

 

 

 

 

 

 

 

 

 

 

 

62

178

67

207

 

72

239

77

274

 

 

 

 

 

 

 

 

 

 

 

63

183

68

214

 

73

246

78

281

 

 

 

 

 

 

 

 

 

 

 

64

189

69

220

 

74

252

 

79 and over

295

 

 

 

 

 

 

 

 

 

 

 

680-001

2019 Printing

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entering details in bsa medical form pdf step 1

Please submit the data inside the area List, participant, restrictions, if, any None, Participants, signature, Date Parent, guardian, signature, for, youth, Date If, participant, is, under, the, age, of Name, Name, Phone, Phone, Name, Name, Phone, and Phone.

step 2 to entering details in bsa medical form pdf

You could be required certain crucial details to be able to fill in the Full, name, Dateofbirth or, staff, position Age, Gender, Height, inches, Weight, lbs Address, City, State, ZIP, code, Phone Unit, leader, Unit, leaders, mobile Council, Name, NoUn, it, No Name, Relationship Address, Home, phone, Other, phone and Alternate, contact, name, Alternates, phone section.

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Entering details in bsa medical form pdf stage 5

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