Fillable Adult Health History Form

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Adult Health History Form

On average this form takes 36 minutes to complete

The Adult Health History Form form is 3 pages long and contains:

  • 0 signatures
  • 79 check-boxes
  • 109 other fields

Country of origin: OTHERS
File type: PDF

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│ │ │
Food:
Plants/Trees Insect Sting
October 2021
│ │ │
COVID-19
October 2021
YES or NO
COVID-19
Please complet
e fully
Flu Shot
Measles (Requir
ed)
P
ertussis
(Whooping Cough-Required)
Rubella
(German Measle
s)
All my vaccinations are up to date.
Other:
MEDICATIONS
• To my best knowledge this health history is correct.
• I am able to engage in all planned trip activities except as noted by the examining physician.
• I acknowledge that an inherent risk of exposure to COVID-19 exists for any in-person activity, including meetings,
activities, events, and trips.
• I am voluntarily assuming all risks related to exposure to COVID-19 and agree not to hold Girl Scouts of Northern
California, or any of its directors, employees, agents or volunteers, liable for any illness or injury.
│ │ │
October 2021
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Adult Health History Form

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Completed 27 May 2022

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