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 certified and licensed health-care provider. In an effort to provide better care to those who may become illor 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 praviding medical information prior to participating in various activities. Those standards are offered below in one three-part medical form, Note that unit laaders 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 forall 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 lst of medications. Part C also includes the parental informed consent and fold harmless/release agreement (ith an area for notarzation it required by your state) as well as a talent release statement, Adult unt leaders should review participants’ heatth histories and become knowledgeable about the medical needs of the youth members in their unit. This form is to be filed out by participants and parents or guardians and kept on fle for easy reference. Part B is required with parts A and C for any event that exceeds 72 consecutive hours, a resident camp setting, or when the nature of the activity Is strenuous and demanding, such as service projects, work ‘weekends, o high-adventure treks. itis to be completed and signed by a certified and licensed health-care provider—physician (MD, DO), nurse practitioner, oF 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. Itis important to note that the height/weight chart must be strictly adhered to ifthe event wil 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 identified that the following risk factors may define your participation in various outdoor adventures. + Sxcessive body woight Asthma * Heart disease * Sleep disorders * Hypertension (high blood pressure) * Alleygies/anaphylaxis * Diabetes * Muscular/skeletal injuries * Seizures + Psychiatric/psychological and emotional cificulties * Lack of appropriate immunizations For more information on medical risk factors, visit Scouting Safely on warw.scouting.org. Prescriptions ‘The taking of prescription medication is the responsibilty of the individual taking the medication and/or that individuals parent or guardian. A leader, ater obtaining all the necessary information, can agree to accept the responsibilty 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. &| BOY SCOUTS OF AMERICA.Emergency contact No.: Allergies: Dos: Last name: Annual BSA Health and Medical Record Part A GENERAL INFORMATION Ha secrets ote ofbitn age le erste ates Grade completed youtn only) city __ Sia Z. Prove No, Unit leer CCouneit nama. Urit No Z Social Securty No optonsk my erga by mecca laces erteaimen Religious proerence Heatvaccisent insurance company Pty No, ATTACH A PHOTOCOPY OF BOTH SIDES OF INSURANCE CARD (SEE PART C). IF FAMILY HAS NO MEDICAL INSURANCE, STATE "NONE" Incase of emergency, notity: Name eetonstip Adress ee - z Eee Home phone Business phone cet phone ‘Aternate contact, rates pone ‘MEDICAL HISTORY ‘re younow, or have you ever been treated for any of the foto Allergies or Reaction to: Yee | tio ‘Condition Bah Medtoation HEE Tere ‘Atha: Food, Plant, or ngoct Bites Diabetes Hypertension igh blood press) Heat cease e, CHF, CAD, MM z Immunizations: ‘The folowing are recommeded by he BSA Slat Tutt teed “res - ron Syne rw eee tS om ety tre esata ‘Musoular/sketotal condition on Nena pbs eae epee oetanepe cea es Sonal ronan Cran ds, ADO TOD, ope a OO yet 7 Fang = OO Mere = Tho dss 8 8 pe —— | Kianey cisease © cticsanpox = Sickle ool disease GG Hepatis | fare OG tone Sep do Fe, ds a BE ies Sprsle (saion Se Eee wines are Super (For more information about immunizations, 25 Soca Golesi teantston sotgetemnees a Spear indoors MEDIoATIONS List al medications curently used. (f additional space is needed, please photocopy this pat ofthe health form) Intalers and EpiPan information must be included, oven f thay are for occasional or emergency use only. weaeston Wedeston Meeaton ‘Svengh Fomenay ‘Svongt Freeueney Seength Frequenay Frasentormediaton Reason or madiation Reason formedcabon ‘Approsinaa gate stxieg | Fepronmase sae sors ‘Approximate dae stared “emparyLJeamnanansC] Temporary ]Pemanmel] Tamporan{_]Permanre(=] Mediation Wesson oseaton Srength Fema ‘engi Freauenay Svengt Freqnay Reason for esiation Reason frmediaton Fson formation ‘Approximate dato started | Approximate date stated ‘Approximate date started — ‘emporan{]Pomanont(] Temporal ]Permanert ‘eemorayl 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 Helght___ Weight____Moets height/weight imits[7]Ves EJNo Blood pressure___ Pulse Individuals desiring to participate In any high-adventure activity or events in which emergency evacuation would take longer than 20 minutes by ground transportation will not be permitted to do so if thoy oxcoad the weight limit as decumented at the ‘bottom ofthis page. Enforcing the height/weight limit is strongly encouraged for all other events, but itis not mandatory. (For healthy height/weight guidelines, visit wwvw.cde.go) ermal | atnormat | 200 | Rangearmcoity | normal | amnemnat | SDS Any ere eee Ear es Nowe om Trost Lange oir ve] Yt Sas Aen Darra Gonta Bao si gua hia Boon rot ede susp: Se ePar od Allergies (to what agont, type of reaction, reatme | cettity that have, today, ravlewad the health history, examined this person, and approve this indvidual for partclpation i C Hiking and camping OQ Competitive activities CO Backpacking ©) Swimmingiwater activites O Cimbing/reppeting 1 Sports ‘O]Horsebackriding Scuba diving C1 Mountain biking G Chatenge ("rope") course 1 Cold-weather activity (<10°F) 1D Wildemessybackcountry treks Specify estictions (none, so state) Certified and licensed health-care providers recognized by the BSA to perform this exam include physicians (MD, DO), nurse practitioners, and physician's agsistants, ‘To Health Care Provider: Restricted approval includes: Provider printed name ‘> Unoontroled heart disease, asthma, or hypertension. > Uncontroled psychiatric disorders. oe > Poorly controled diabetes. Address > Orthopedic injures not cleared by a physician. aoa > Newly diagnosed seizure events (nithin 6 months). > For scuba, use of medications to contol diabetes, asthma, Office phone, or soizures Date Height | Recommended | Allowable | Maximum Height | Recommended | Allowable | Maximum (imenes)_| “weight as) _| Exception | Acceptance | | inches) | Weight (bs) | Exception | Acceptance o 97-136, 130-165 185, 70 ard 189-226 28 a 04s ETA 1 i 196-104 795203, 239 ma ET T4178 78 7 40-189) 200-238 239 3 sors 159-163, 185 72 164-205, 206-248 248 et 187 3150-109 188 74 46230. 2r-252 252 co sa 162 168-195 195 % 162216 217-260 260 68 18.167 188-201 201 75 156222 2207 267 Gl TeHire 179.207 207, tr 160-228, Za878 27 68 72888 raza 2 7 164234 235-281 281 63 120-185, 198-220, 20 Toaover | 170-240 21285 285 ‘This table is based on te revised Dictary Guidelines for Amarcans rom the US. Dept of Agriculture and the Dep. of Health & Human Services. PartB Last name: oy DOB: