Girls Scout of the Philippines

SUTAN KUDARAT COUNCIL

Tacurong City
HEALTH EXAMINATION FORM
Name: _____________________________________________ Birth Date: ___________________ Age: _____
Surname
First
Middle Name
Address: ________________________________________________________ Tel/Cel:___________________
In Case of Emergency, please notify:
Name: _______________________________________________ Relationship: ___________________
Address: _____________________________________________ Tel/Cel #: _____________________
__________________________________________________________________________________________
Past Personal History: (To be filled-up by applicant before presentation to the physician)
Illness suffered _____________________________________________________________________________
Previous accidents and/or injury:_______________________________________________________________
Surgical Operation, if any: ____________________________________________________________________
Allergy (drugs, food or materials, etc.) __________________________________________________________
Blood Type: _______________ Immunization (Give the ID and Date): ________________________________
__________________________________________________________________________________________
Any specific actibvities to be ENCOURAGED? ___________________________________________________
DISCOURAGED? __________________________________________________
Sugestion:

In case of emergency, I hereby give permission to the Physician selected by the Coordinator to
give treatment, order injection, hospitalize, give anethesia or perform surgery for our
son/daughter.
_____________________________
Signature of Parent/Guardian

__________________________________________________________________________________________
PHYSICIAN EXAMINATION
- To be filled-up by licensed physician
Code V = Satisfactory
X = Not Satisfactory ( Please explain)
Hieght: _____________________________
Blood Pressure: ____________________________
Weight: ____________________________
Circulatory System: _________________________
Eyes: ______________________________
Blood Analysis: ____________________________
Ears: ______________________________
Urinal Analysis: ____________________________
Nose: ______________________________
Loco-Motor System: ________________________
Throat: _____________________________
Nervous System: ___________________________
Heart: _____________________________
Skin: _____________________________________
Abdomen: _________________________
Lungs: ___________________________________
Allergy (Please specify if any): ________________________________________________________________
Menstrual History: __________________________________________________________________________
Genetalia: _________________________________________________________________________________
Recommendations and restriction (diet, medicine, swimming, driving, etc.)
__________________________________________________________________________________________
__________________________________________________________________________________________

______________________________
Examining Physician
Address: ____________________________________________________ Tel. No: ______________________