Boy Scout Physical Form Details

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QuestionAnswer
Form NameFillable Bsa Health Form
Form Length4 pages
Fillable?Yes
Fillable fields226
Avg. time to fill out23 min 8 sec
Other namesbsa health form 2020 pdf, bsa medical form part c pdf, bsa health form 2021 pdf, boy scout medical form

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Annual Health and Medical Record

(Valid for 12 calendar months)

Medical Information

The Boy Scouts of America recommends that all youth and adult members have annual medical evaluations by a certiied and licensed health-care provider. In an effort to provide better care to those who may become ill or injured and to provide youth members and adult leaders a better understanding of their own physical capabilities, the Boy Scouts of America has established minimum standards for providing medical information prior to participating in various activities. Those standards are offered below in one three-part medical form. Note that unit leaders must always protect the privacy of unit participants by protecting their medical information.

Parts A and C are to be completed annually by all BSA unit members. Both parts are required for all events that do not exceed 72 consecutive hours, where the level of activity is similar to that normally expended at home or at school, such as day camp, day hikes, swimming parties, or an overnight camp, and where medical care is readily available. Medical information required includes a current health history and list of medications. Part C also includes the parental informed consent and hold harmless/release agreement (with an area for notarization if required by your state) as well as a talent release statement. Adult unit leaders should review participants’ health histories and become knowledgeable about the medical needs of the youth members in their unit. This form is to be illed out by participants and parents or guardians and kept on ile for easy reference.

Part B is required with parts A and C for any event that exceeds 72 consecutive hours, or when the nature of the activity is strenuous and demanding, such as a high-adventure trek. Service projects or work weekends may also it this description. It is to be completed and signed by a certiied and licensed health-care provider—physician (MD, DO), nurse practitioner, or physician’s assistant as appropriate for your state. The level of activity ranges from what is normally expended at home or at school to strenuous activity such as hiking and backpacking. Other examples include tour camping, jamborees, and Wood Badge training courses. It is important to note that the height/weight limits must be strictly adhered to if the event will take the unit beyond a radius wherein emergency evacuation is more than 30 minutes by ground transportation, such as backpacking trips, high-adventure activities, and conservation projects in remote areas.

Risk Factors

Based on the vast experience of the medical community, the BSA has identiied that the following risk factors may deine your participation in various outdoor adventures.

• Excessive body weight

• Asthma

• Heart disease

• Sleep disorders

• Hypertension (high blood pressure)

• Allergies/anaphylaxis

• Diabetes

• Muscular/skeletal injuries

• Seizures

• Psychiatric/psychological and emotional dificulties

• Lack of appropriate immunizations

 

For more information on medical risk factors, visit Scouting Safely on www.scouting.org.

Prescriptions

The taking of prescription medication is the responsibility of the individual taking the medication and/or that individual’s parent or guardian. A leader, after obtaining all the necessary information, can agree to accept the responsibility of making sure a youth takes the necessary medication at the appropriate time, but BSA does not mandate or necessarily encourage the leader to do so. Also, if state laws are more limiting, they must be followed.

For frequently asked questions about this Annual Health and Medical Record, see Scouting Safely online at http://www.scouting.org/scoutsource/HealthandSafety.aspx. Information about the Health Insurance Portability and Accountability Act (HIPAA) may be found at http://www.hipaa.org.

contact No.: ___________________

Annual BSA Health and Medical Record

Part A

GENERAL INFORMATION

Name ___________________________________________________________________ Date of birth ________________________________ Age _____________ Male

Female

Address _________________________________________________________________________________________________________________________ Grade completed (youth only) __________

City _____________________________________________________________________ State ____________ Zip ____________________________ Phone No. ________________________________

Unit leader ______________________________________________________ Council name/No. ___________________________________________ Unit No. ___________________

Social Security No. (optional; may be required by medical facilities for treatment) _______________________ Religious preference ______________________________

Health/accident insurance company __________________________________________________________ Policy No. ________________________________________________________

ATTACH A PHOTOCOPY OF BOTH SIDES OF INSURANCE CARD (SEE PART C). IF FAMILY HAS NO MEDICAL INSURANCE, STATE “NONE.” In case of emergency, notify:

Name _________________________________________________________________________________ Relationship _____________________________________________________________

Address _________________________________________________________________________________________________________________________________________________________________

Home phone _________________________________________ Business phone _______________________________ Cell phone ___________________________________________

Alternate contact _________________________________________________________________________ Alternate’s phone ___________________________________________________

DOB: ______________ Allergies: __________________ Emergency

MEDICAL HISTORY

Are you now, or have you ever been treated for any of the following:

Yes

No

Condition

Explain

Asthma

Diabetes

Hypertension (high blood pressure)

Heart disease (i.e., CHF, CAD, MI)

Stroke/TIA

COPD

Ear/sinus problems

Muscular/skeletal condition

Menstrual problems (women only)

Psychiatric/psychological and emotional dificulties

Learning disorders (i.e., ADHD, ADD)

Bleeding disorders

Fainting spells

Thyroid disease

Kidney disease

Sickle cell disease

Seizures

Sleep disorders (i.e., sleep apnea)

GI problems (i.e., abdominal, digestive)

Surgery

Serious injury

Other

MEDICATIONS

List all medications currently used. (If additional space is needed, please photocopy this part of the health form.) Inhalers and EpiPen information must be included, even if they are for occasional or emergency use only.

Allergies or Reaction to: Medication _______________________________________

Food, Plants, or Insect Bites ____________________

____________________________________________________

Immunizations:

The following are recommended by the BSA. Tetanus immunization must have been received within the last 10 years. If had disease, put “D” and the year. If immunized, check the box and the year received.

Yes No Date

Tetanus ____________________________

Pertussis __________________________

Diptheria __________________________

Measles ___________________________

Mumps ____________________________

Rubella ____________________________

Polio _______________________________

Chicken pox_______________________

Hepatitis A ________________________

Hepatitis B ________________________

Inluenza __________________________

Other (i.e., HIB) ___________________

Exemption to immunizations claimed.

(For more information about immunizations, as well as the immunization exemption form, see Scouting Safely on Scouting.org.)

Last name: ________________________________

Medication _____________________________

Medication _____________________________

Medication _____________________________

Strength ________ Frequency ____________

Strength ________ Frequency ____________

Strength ________ Frequency ____________

Approximate date started ________________

Approximate date started ________________

Approximate date started ________________

Reason for medication ___________________

Reason for medication ___________________

Reason for medication ___________________

________________________________________

________________________________________

________________________________________

Distribution approved by:

Distribution approved by:

Distribution approved by:

____________________ /___________________

____________________ /___________________

____________________ /___________________

Parent signature

MD/DO, NP, or PA Signature

Parent signature

MD/DO, NP, or PA Signature

Parent signature

MD/DO, NP, or PA Signature

Temporary

Permanent

Temporary

Permanent

Temporary

Permanent

 

 

 

Medication _____________________________

Medication _____________________________

Medication _____________________________

Strength ________ Frequency ____________

Strength ________ Frequency ____________

Strength ________ Frequency ____________

Approximate date started ________________

Approximate date started ________________

Approximate date started ________________

Reason for medication ___________________

Reason for medication ___________________

Reason for medication ___________________

________________________________________

________________________________________

________________________________________

Distribution approved by:

Distribution approved by:

Distribution approved by:

____________________ /___________________

____________________ /___________________

____________________ /___________________

Parent signature

MD/DO, NP, or PA Signature

Parent signature

MD/DO, NP, or PA Signature

Parent signature

MD/DO, NP, or PA Signature

Temporary

Permanent

Temporary

Permanent

Temporary

Permanent

 

 

 

 

 

 

NOTE: Be sure to bring medications in the appropriate containers, and make sure that they are NOT expired,

including inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance medication.

Part B

PHYSICAL EXAMINATION

Height____________ Weight ____________ % body fat___________ Meets height/weight limits Yes No

Blood pressure ___________ Pulse ____________

Individuals desiring to participate in any high-adventure activity or event in which emergency evacuation would take longer than 30 minutes by ground transportation will not be permitted to do so if they exceed the height/weight limits as documented in the table at the bottom of this page or if during a physical exam their health care provider determines that body fat percentage is outside the range of 10 to 31 percent for a woman or 2 to 25 percent for a man. Enforcing this limit is strongly encouraged for all other events, but it is not mandatory. (For healthy height/weight guidelines, visit www.cdc.gov.)

 

Normal

Abnormal

Explain Any

Range of Mobility

Normal

Abnormal

Explain Any

 

Abnormalities

Abnormalities

 

 

 

 

 

 

Eyes

 

 

 

Knees (both)

 

 

 

 

 

 

 

 

 

 

 

Ears

 

 

 

Ankles (both)

 

 

 

 

 

 

 

 

 

 

 

Nose

 

 

 

Spine

 

 

 

 

 

 

 

 

 

 

 

Throat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lungs

 

 

 

Other

Yes

No

 

 

 

 

 

 

 

 

 

Heart

 

 

 

Contacts

 

 

 

 

 

 

 

 

 

 

 

Abdomen

 

 

 

Dentures

 

 

 

 

 

 

 

 

 

 

 

Genitalia

 

 

 

Braces

 

 

 

 

 

 

 

 

 

 

 

Skin

 

 

 

Inguinal hernia

 

 

Explain

 

 

 

 

 

 

 

 

Emotional

 

 

 

Medical equipment

 

 

 

adjustment

 

 

 

(i.e., CPAP, oxygen)

 

 

 

 

 

 

 

 

 

 

 

Tuberculosis (TB) skin test (if required by your state for BSA camp staff)

Negative

Positive

Allergies (to what agent, type of reaction, treatment): __________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________

I certify that I have, today, reviewed the health history, examined this person, and approve this individual for participation in:

Hiking and camping

Competitive activities

Sports

Horseback riding

Cold-weather activity (<10°F)

Backpacking

Swimming/water activities

Scuba diving

Mountain biking

Wilderness/backcountry treks

Climbing/rappelling Challenge (“ropes”) course

Specify restrictions (if none, so state) ____________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Certiied and licensed health-care providers recognized by the BSA to perform this exam include physicians (MD, DO), nurse practitioners, and physician’s assistants.

To Health Care Provider: Restricted approval includes:

Uncontrolled heart disease, asthma, or hypertension.

Uncontrolled psychiatric disorders.

Poorly controlled diabetes.

Orthopedic injuries not cleared by a physician.

Newly diagnosed seizure events (within 6 months).

For scuba, use of medications to control diabetes, asthma, or seizures.

Height

Recommended

Allowable

Maximum

(inches)

Weight (lbs)

Exception

Acceptance

 

 

 

 

60

97-138

139-166

166

 

 

 

 

61

101-143

144-172

172

 

 

 

 

62

104-148

149-178

178

 

 

 

 

63

107-152

153-183

183

 

 

 

 

64

111-157

158-189

189

 

 

 

 

65

114-162

163-195

195

 

 

 

 

66

118-167

168-201

201

 

 

 

 

67

121-172

173-207

207

 

 

 

 

68

125-178

179-214

214

 

 

 

 

69

129-185

186-220

220

 

 

 

 

Provider printed name ______________________________________________________

Signature _______________________________________________________________________

Address ________________________________________________________________________

City, state, zip _________________________________________________________________

Ofice phone __________________________________________________________________

Date _____________________________________________________________________________

Height

Recommended

Allowable

Maximum

(inches)

Weight (lbs)

Exception

Acceptance

 

 

 

 

70

132-188

189-226

226

 

 

 

 

71

136-194

195-233

233

 

 

 

 

72

140-199

200-239

239

 

 

 

 

73

144-205

206-246

246

 

 

 

 

74

148-210

211-252

252

 

 

 

 

75

152-216

217-260

260

 

 

 

 

76

156-222

223-267

267

 

 

 

 

77

160-228

229-274

274

 

 

 

 

78

164-234

235-281

281

 

 

 

 

79 & over

170-240

241-295

295

 

 

 

 

This table is based on the revised Dietary Guidelines for Americans from the U.S. Dept. of Agriculture and the Dept. of Health & Human Services.

Part B Last name: _________________________________________ DOB: ___________________

Part C

Informed Consent and Hold Harmless/Release Agreement

I understand that participation in Scouting activities involves a certain degree of risk. I have carefully considered the risk involved and have given consent for myself and/or my child to participate in these activities. I understand that participation in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I 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 claims or liability arising out of this participation.

I approve the sharing of the information on this form with BSA volunteers and professionals who need to know of medical situations that might require special consideration for the safe conducting of Scouting activities.

In case of an emergency involving me or my child, I understand that every effort will be made to contact the individual listed as the emergency contact person. 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 to the adult in charge Protected Health Information/ Conidential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identiiable Health Information, 45 C.F.R. §§160.103, 164.501, etc. seq., as amended from time to time, including examination indings, 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.

Without restrictions.

With special considerations or restrictions (list) ____________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

I hereby assign and grant to the local council and the Boy Scouts of America the right and permission to use and publish the photographs/ ilm/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 hereby authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/ ilm/videotapes/electronic representations and/or sound recordings without limitation at the discretion of the Boy Scouts of America, and I speciically waive any right to any compensation I may have for any of the foregoing.

YesNo

Adults authorized to take youth to and from the event: (You must designate at least one adult. Please include a telephone number.)

Adults NOT authorized to take youth to and from the event:

1.

_____________________________________________________________________

1.

_____________________________________________________________________

2.

_____________________________________________________________________

2.

_____________________________________________________________________

3.

_____________________________________________________________________

3.

_____________________________________________________________________

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.

Participant’s name ______________________________________________________________________________________________________________________________

Participant’s signature ________________________________________________________________________________________________________________________

Parent/guardian’s signature ________________________________________________________________________________________________________

(if under the age of 18)

Date ________________________________________________

Attach copy of insurance card (front and back) here. If required by your state, use the space provided here for notarization.

Boy ScoutS of AmericA

1325 West Walnut Hill Lane P.o. Box 152079

irving, texas 75015-20797 http://www.scouting.org

SKU 34605

30176 34605

2

34605

2009 Printing

Part C Last name: _________________________________________ DOB: ___________________

Rev. 9/2009

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bsa medical form part c pdf empty spaces to fill in

Fill out the : s e g r e, l l, B O D, Heart disease (i, Stroke/TIA, COPD, Ear/sinus problems, Muscular/skeletal condition, Menstrual problems (women only), MEDICATIONS List all medications, Immunizations:, The following are recommended by, Yes No Date, Tetanus Pertussis Diptheria , and Exemption to immunizations claimed section with all the details requested by the application.

Filling out bsa medical form part c pdf stage 2

Identify the necessary data in the e m a n t s a L, Medication Strength Frequency , Medication Strength Frequency , Medication Strength Frequency , Temporary, Permanent, Temporary, Permanent, Temporary, Permanent, Medication Strength Frequency , Medication Strength Frequency , Medication Strength Frequency , Temporary, and Permanent box.

Completing bsa medical form part c pdf part 3

The Part B PHYSICAL EXAMINATION, Height Weight % body fat Meets, Yes, Individuals desiring to, Normal, Abnormal, Explain Any Abnormalities, Range of Mobility, Normal, Abnormal, Explain Any Abnormalities, Eyes, Ears, Nose, and Throat area will be your place to insert the rights and obligations of both parties.

part 4 to finishing bsa medical form part c pdf

End by reviewing all these fields and preparing them as required: Hiking and camping Sports, Competitive activities Horseback, Backpacking Scuba diving, Swimming/water activities Mountain, Climbing/rappelling Challenge, Specify restrictions (if none, Certiied and licensed health-care, To Health Care Provider:, or seizures, Provider printed name , Signature , Address , City, Ofice phone , and Date .

part 5 to filling out bsa medical form part c pdf

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