Boy Scout Camp Physical Form
| I understand that in my participation in the scouting activities, such involves risk of physical injury or death. I understand that participation in such activities are voluntary with proper instructions to abide to by participants, subject to applicable and standards of conduct. In case of emergency, I understand that all possible efforts shall be made by the medical service provider and/or the scout leader to contact my designated person in case of emergency. In case the designated contact is unreachable, the scout leader in charge shall give permission to the medical provider to to conduct the necessary proper treatment, including hospitalization, anesthesia, or surgery, among others. In case needed, medical providers may disclose the protected health information to the leader in charge, camp medical staff and management as o the findings from observations, test results, and treatment. Further, I give authorization to any volunteer employed by the organization whom knowledge of such information is needed in consideration of the conditions for conducting activities. |
| Yes/No | Details | |
|---|---|---|
| Asthma | No | |
| Diabetes | No | |
| Congenital Heart Disease | No | |
| Chronic obstructive pulmonary disease (COPD) | No | |
| Hypertension | No | |
| Any lung/respiratory disease | No | |
| Ear/eyes/nose/sinus problems | No | |
| Muscular or skeletal condition | No | |
| Had history of a head injury/concussion | No | |
| Altitude or Travel sickness | No | |
| Kidney disease | No | |
| Blood disorders/sickle cell disease | No | |
| Fainting spells and dizziness | No | |
| Psychological or emotional difficulties or Behavioral/neurological disorders | No | |
| Seizures (please indicate last occurrence): | No | |
| Abdominal, stomach, digestive problems | No | |
| Thyroid disease | No | |
| Excessive fatigue | No | |
| Obstructive sleep apnea/sleep disorders | No |
| With Allergies | Details | |
|---|---|---|
| Medicine / Antibiotics | penicillin | |
| Food | crabs | |
| Insects | bees | |
| Animals | ||
| Plants |
| Immunized | Contracted Disease | Details (Including date) | |
|---|---|---|---|
| Chicken Pox | No | Yes | had chicken pox 3 years ago. fully recovered |
| Diphtheria | No | No | |
| Hepatitis A | Yes | No | |
| Hepatitis B | Yes | No | |
| Influenza | Yes | No | |
| Meningitis | Yes | No | |
| Measles/mumps/rubella | Yes | No | |
| Tetanus | No | No | |
| Pertussis | Yes | No | |
| Polio | Yes | No | |
| Other (i.e. HIB) | Yes |
| Status | Details | |
|---|---|---|
| Abdomen | Normal | |
| Eyes | Normal | |
| Ears | Normal | |
| Genitalia/hernia | Normal | |
| Nose | Normal | |
| Throat | Normal | |
| Lungs | Normal | |
| Heart | Normal | |
| Musculoskeletal | Normal | |
| Neurological | Normal | |
| Other |
| With Allergies | Details | |
|---|---|---|
| Medicine / Antibiotics | penicillin | |
| Food | crabs | |
| Insects | bees | |
| Animals | ||
| Plants |
Height/Weight Restrictions
If participant exceeds the maximum weight for the height indicated in the chart below, participant may not be allowed to join a high-adventure activity.
Maximum weight for height:
| Height (inches) | Max. Weight |
| 60 | 166 |
| 61 | 172 |
| 62 | 178 |
| 63 | 183 |
| 64 | 189 |
| Height (inches) | Max. Weight |
| 65 | 195 |
| 66 | 201 |
| 67 | 207 |
| 68 | 214 |
| 69 | 220 |
| Height (inches) | Max. Weight |
| 70 | 226 |
| 71 | 233 |
| 72 | 239 |
| 73 | 246 |
| 74 | 252 |
| Height (inches) | Max. Weight |
| 75 | 260 |
| 76 | 267 |
| 77 | 274 |
| 78 | 281 |
| 79 and over | 295 |
| Meets height/weight requirements | Satisfied |
|---|---|
| No uncontrolled heart disease, asthma, or hypertension | Satisfied |
| Does not have muscoskeletal problems | Satisfied |
| Has not had an orthopedic injury and/or orthopedic surgery in the last six months or possesses a clearance certified by his orthopedic surgeon or treating physician. | Satisfied |
| No uncontrolled psychiatric disorders. | Satisfied |
| Has not had seizures in the last year. | Satisfied |
| Does not have poorly controlled diabetes (if applicable). | Satisfied |
| For scuba diving participants: does not have diabetes, asthma, or seizures; or use of medications to control diabetes, asthma, or seizures is property maintained. |
I certify that I have examined the physical fitness and health history of this person, by which the information indicated above reflects are true and correct:
A Boy Scout Camp Physical Form is a health information form that is compliant to the standards of the Boy Scouts of America. This is a necessary document for any camping activity longer than three consecutive days. This form acts as a multi-purpose form by promoting health awareness. It also serves as an information reference for health officials who may give the person treatment in case of illness or injury during the camping trip. This also serves as the participant's physical preparedness for specialized activities like a jamboree.
This Boy Scout Camp Physical Form PDF template is your quick and comprehensive form for both the applicant and the physician. With the use of the web form, participants or applicants can fill the form and submit it online. No need to fill out paper documents and have better filing management with a database on the cloud. Have a copy of this Jotform based Boy Scout Camp Physical Form PDF Template and start receiving physical fitness forms for your boy scout activities!
Child Medical History Template
This child medical history PDF template makes checking patients vitals and recording that important data easy. Add your own branding, adjust fields for your specific needs and then simply print out your PDF for the patient's file.
First Aid Incident Report Template
Incidents must be reported and recorded to be sure that correct actions and treatment are made which should trigger management awareness and an investigation. The First-Aid Incident Report template contains injured person's personal details and contact details, the details and visible symptoms of injury, the Glasgow Coma Scale which is a neurological scale that expects to give a dependable and target method for chronicle the condition of an individual's awareness and brief information of treatment. Also, it contains the profile of the first-aider and signature of the person who prepares the report.
Professional Medical History Template
Medical History Record PDF template is here to help you in order to know the patient's case and previous condition. You can collect data about the patient and medical background with this Medical History Record PDF sample.
Patient Medical Record Template
Medical History Record PDF template lets you collect the patient's data such as personal information, contact information in an emergency case, general medical history. By using this sample, the doctor ensures the patient's better care and treatment.
COVID-19 Vaccine Administration Record
Keep track of patient vaccination records online. More secure with GDPR, CCPA, and optional HIPAA compliance features. Download or print as PDFs. Free, easy-to-customize template.
Veterinary Hospital Treatment Sheet Template
Veterinary Hospital Treatment Sheet helps both the hospital and pet owners in understanding and tracking a pet's treatment process. Just like any other hospitals, keeping patient's treatment records is necessary to monitor progress and make sure proper treatment is given. Having a veterinary treatment sheet also helps in planning and evaluating other treatments for the pet, facilitating research and creating a record for the pet's future care. If you are trying to create a treatment sheet and looking for a sample template, then look no further because Jotform offers a Veterinary Hospital Treatment Sheet template you can download, save, edit and print. This Veterinary Treatment Sheet template contains the necessary information for recording and tracking treatment process for your client's pet. It has information such as name of client, date and time, address, contact number, treatment performed, doctor's name, monitoring progress report and many more. This template is editable and allows you to add more information or remove if you need to. Add your hospital's logo or insert images to make it more personalized.
These templates are suggested forms only. If you're using a form as a contract, or to gather personal (or personal health) info, or for some other purpose with legal implications, we recommend that you do your homework to ensure you are complying with applicable laws and that you consult an attorney before relying on any particular form.