Name: ___________________________ Date: ___________________________

1. Allergies and Medical Conditions

Do you have any allergies? (For example: peanuts, bee stings, pollen)
☐ Yes ☐ No If yes, what are they? ___________________________________________

Do you have any medical conditions that could affect your participation in physical activities?
☐ Yes ☐ No If yes, what are they? ___________________________________________

2. Activity Limits

Are there any activities that you should avoid or be careful doing? (For example: running, swimming, climbing)
☐ Yes ☐ No If yes, what activities? ___________________________________________

3. First Aid and Emergency Information

Do you carry any medications, such as an inhaler or EpiPen?
☐ Yes ☐ No If yes, what is it for? ___________________________________________

4. Staying Safe

What should you do if you start feeling unwell or hurt during an activity?

Why is it important to know your own health needs before doing physical activities?

5. Parent or Guardian Review

I have reviewed the BSA Annual Health and Medical Record with my scout.

Parent/Guardian Signature: ___________________________

For more information, see https://scoutermom.com/50138/webelos-stronger-faster-higher-den-meeting/