Health-and-Medical-Certificate

MUNICIPAL WEEKEND ADVANCEMENT CAMP
HEALTH AND MEDICAL RECORD

This health and medical record, including limitations indicated, is valid for participation in the Scouting Program for one
year date of physician’s examination subject to recertification in camp and when required for special events.
Please fill out completely
HEALTH HISTORY
Have or subject to (check if yes):
Fainting Spells Palpitation Abdominal Pain Nervousness Shortness of Breath
Headache Convulsions Frequent Cough Easy Fatigue Frequent Fever
Chest Pain Others:
Describe: ________________________________________
Have or subject to trouble with (check if yes): Have had: (check if yes) YEAR
Eye, Ear, Nose, Throat Hernia Allergy Measles _______________
Recurrent Diarrhea Heart Lungs Mumps _______________
Hypertension Kidney Malaria Chicken Pox _______________
Diabetes Whooping Cough _______________
Any condition now requiring regular medication? _________________________________________________________

Any restriction of activity for medical reasons? ___________________________________________________________
Explain___________________________________________________________________________________________
IMMUNIZATION Date of last inoculation Date of last inoculation

Smallpox _________________ Polio (Short or Oral) ___________________
Diphtheria _________________ Others ___________________
Tetanus Toxoid _________________
If applicant is under 21 years of age:
In the event of illness or injury occurring to my son during his attendance at the Jamboree / Training, I do hereby consent to advance to
whatever medical or surgical diagnostic procedure or treatment is considered necessary in the best judgement of the attending
physician and performed by or under the supervision of a member of the medical staff furnishing medical services. I understand that, in
the event of a serious illness or injury, reasonable efforts to reach me will be attempted.
Signed: __________________________ Date: ____________________ Approved by: ________________________

Applicant Parent or Guardian
MEDICAL EXAMINATIONS
TO THE PHYSICIAN: Your careful examination and written recommendation will encourage personal fitness and safe
participation in strenuous outdoor activities. Review health history. If incomplete, please ask that this essential information
be provided for your use.
PHYSICAL FINDINGS
Normal Abnormal Explanation if abnormal
Eyes __________________________________________________________
Vision __________________________________________________________
Ears __________________________________________________________
Nose __________________________________________________________
Throat __________________________________________________________
Teeth __________________________________________________________
Lungs __________________________________________________________
Heart __________________________________________________________
Blood Pressure __________________________________________________________
Abdomen __________________________________________________________
Hernia __________________________________________________________
Genitalia __________________________________________________________
Extremities __________________________________________________________
Posture (Spine) __________________________________________________________
Skin __________________________________________________________
Urinalysis __________________________________________________________
Emotional Stability __________________________________________________________
IMMUNIZATION (See history) (Check One) Date Given

OK Needed
Smallpox ___________________________
Diphtheria ___________________________
Tetanus Toxoid ___________________________
Polio ___________________________
Cholera / Dysentery / Typhoid ___________________________
I certify that I have reviewed the health history and examined this person and find him physically fit to participate in:
Camping & Hiking Water Sports Competitive Sports
Recommendations and/or restrictions (if none, so state): ___________________________________________________

Signed: _________________________________________ Signed: __________________________________________
Examinee Physician and License No.

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MUNICIPAL WEEKEND ADVANCEMENT CAMP

HEALTH AND MEDICAL RECORD

Any condition now requiring regular medication? _________________________________________________________

IMMUNIZATION Date of last inoculation Date of last inoculation

If applicant is under 21 years of age:

Signed: __ Date: Approved by:

IMMUNIZATION (See history) (Check One) Date Given

Recommendations and/or restrictions (if none, so state): ___________________________________________________

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