Annual Health and Medical Record Information and FAQs

Personal Health and the Risk Factors. Scouting activities can be physically and
mentally demanding. Listed below are some of the risk factors that
Annual Health and Medical Record have been known to become issues during outdoor adventures.
• Exessive body weight (obesity) • Sleep apnea
Find the current Annual Health and
• Cardiac or cardiovascular disease • Allergies or anaphylaxsis
Medical Record by using this QR code
or by visiting http://www.scouting.org/ • Hypertension (high blood pressure) • Musculoskeletal injuries
HealthandSafety/ahmr.aspx.
• Diabetes mellitus • Psychological and
emotional difficulties
The Scouting adventure, camping trips, high- • Seizures
adventure excursions, and having fun are important
• Asthma
to everyone in Scouting—and so are your safety and well-being.
Completing the Annual Health and Medical Record is the first step More in-depth information about risk factors
in making sure you have a great Scouting experience. So what do can be found by using this QR code or
you need? by visiting http://www.scouting.org/
HealthandSafety/risk_factors.aspx
All Scouting Events. All participants in all Scouting
activities complete Part A and Part B. Give the completed forms
to your unit leader. This applies to all activities, day camps, local
tours, and weekend camping trips less than 72 hours. Update at
least annually.
Questions?
Q. Why does the BSA require all participants to have an Annual
Part A is an informed consent, release agreement, and authorization Health and Medical Record?
that needs to be signed by every participant (or a parent and/or legal
guardian for all youth under 18). A. The AHMR serves many purposes. Completing a health history
promotes health awareness, collects necessary data, and provides
Part B is general information and a health history. medical professionals critical information needed to treat a patient
in the event of an illness or injury. It also provides emergency
Going to Camp? A pre-participation physical is needed for contact information.
resident, tour, or trek camps or for a Scouting event of more than
72 hours, such as Wood Badge and NYLT. The exam needs to be Poor health and/or lack of awareness of risk factors have led to
completed by a certified and licensed physician (MD, DO), nurse disabling injuries, illnesses, and even fatalities. Because we care
practitioner, or physician assistant. If your camp has provided you about our participants’ health and safety, the Boy Scouts of America
with any supplemental risk information, or if your plans include has produced and required the use of standardized health and
attending one of the four national high-adventure bases, share the medical information since at least the 1930s.
venue’s risk advisory with your medical provider when you are having
your physical exam. The medical record is used to prepare for high-adventure activities
and increased physical activity. In some cases, it is used to review
Part C is your pre-participation physical certification. participants’ readiness for gatherings like the national Scout
jamboree and other specialized activities.
Planning a High-Adventure Trip? Each of the four Because many states regulate the camping industry, this Annual
national high-adventure bases has provided a supplemental risk Health and Medical Record also serves as a tool that enables
advisory that explains in greater detail some of the risks inherent councils to operate day and resident camps and adhere to state and
in that program. All high-adventure participants must read and BSA requirements. The Boy Scouts of America Annual Health and
share this information with their medical providers during their Medical Record provides a standardized mechanism that can be
pre-participation physicals. Additional information regarding high- used by members in all 50 states.
adventure activities may be obtained directly from the venue or your
local council. For answers to more questions, use this
QR code or visit the FAQ page at
Prescription Medication. Taking prescription www.scouting.org/HealthandSafety/
medication is the responsibility of the individual taking the medication Resources/MedicalFormFAQs.aspx.
and/or that individual’s parent or guardian. A leader, after obtaining
all the necessary information, can agree to accept the responsibility Download a free QR reader for your smartphone
of making sure a youth takes the necessary medication at the at scan.mobi.
appropriate time, but the BSA does not mandate or necessarily
encourage the leader to do so. Standards and policies regarding
administration of medication may be in place at BSA camps. If state
laws are more limiting than camp policies, they must be followed.
The AHMR also allows for a parent or guardian to authorize the
administration of nonprescription medication to a youth by a camp
health officer or unit leader, including any noted exceptions.

680-001
2014 Printing
Part A: Informed Consent, Release Agreement, and Authorization A
High-adventure base participants:
Full name: _________________________________________ Expedition/crew No.:________________________________
or staff position:____________________________________
DOB: _________________________________________

Informed Consent, Release Agreement, and Authorization With appreciation of the dangers and risks associated with programs and
activities, on my own behalf and/or on behalf of my child, I hereby fully and
I understand that participation in Scouting activities involves the risk of personal completely release and waive any and all claims for personal injury, death, or
injury, including death, due to the physical, mental, and emotional challenges in the loss that may arise against the Boy Scouts of America, the local council, the
activities offered. Information about those activities may be obtained from the venue, activity coordinators, and all employees, volunteers, related parties, or other
activity coordinators, or your local council. I also understand that participation in organizations associated with any program or activity.
these activities is entirely voluntary and requires participants to follow instructions
and abide by all applicable rules and the standards of conduct. I also hereby assign and grant to the local council and the Boy Scouts of America,
as well as their authorized representatives, the right and permission to use and
In case of an emergency involving me or my child, I understand that efforts will publish the photographs/film/videotapes/electronic representations and/or sound
be made to contact the individual listed as the emergency contact person by recordings made of me or my child at all Scouting activities, and I hereby release
the medical provider and/or adult leader. In the event that this person cannot be the Boy Scouts of America, the local council, the activity coordinators, and all
reached, permission is hereby given to the medical provider selected by the adult employees, volunteers, related parties, or other organizations associated with
leader in charge to secure proper treatment, including hospitalization, anesthesia, the activity from any and all liability from such use and publication. I further
surgery, or injections of medication for me or my child. Medical providers are authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage,
authorized to disclose protected health information to the adult in charge, camp and/or distribution of said photographs/film/videotapes/electronic representations
medical staff, camp management, and/or any physician or health-care provider and/or sound recordings without limitation at the discretion of the BSA, and I
involved in providing medical care to the participant. Protected Health Information/ specifically waive any right to any compensation I may have for any of the foregoing.
Confidential Health Information (PHI/CHI) under the Standards for Privacy of
Individually Identifiable Health Information, 45 C.F.R. §§160.103, 164.501, etc. NOTE: Due to the nature of programs and
seq., as amended from time to time, includes examination findings, test results, and activities, the Boy Scouts of America and local
treatment provided for purposes of medical evaluation of the participant, follow-up councils cannot continually monitor compliance
and communication with the participant’s parents or guardian, and/or determination
of the participant’s ability to continue in the program activities. ! of program participants or any limitations
imposed upon them by parents or medical
providers. However, so that leaders can be as
!
(If applicable) I have carefully considered the risk involved and hereby give my familiar as possible with any limitations, list any
informed consent for my child to participate in all activities offered in the program. restrictions imposed on a child participant in
I further authorize the sharing of the information on this form with any BSA volunteers connection with programs or activities below.
or professionals who need to know of medical conditions that may require special
consideration in conducting Scouting activities. List participant restrictions, if any: None

________________________________________________________

I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in any event or activity. If I
am participating at Philmont, Philmont Training Center, Northern Tier, Florida Sea Base, or the Summit Bechtel Reserve, I have also read and understand the supplemental
risk advisories, including height and weight requirements and restrictions, and understand that the participant will not be allowed to participate in applicable high-adventure
programs if those requirements are not met. The participant has permission to engage in all high-adventure activities described, except as specifically noted by me or the
health-care provider. If the participant is under the age of 18, a parent or guardian’s signature is required.

Participant’s signature:_________________________________________________________________________________________ Date:_______________________________

Parent/guardian signature for youth:______________________________________________________________________________ Date:_______________________________

(If participant is under the age of 18)

Second parent/guardian signature for youth:_______________________________________________________________________ Date:_______________________________

(If required; for example, California)

Complete this section for youth participants only:

Adults Authorized to Take to and From Events:

You must designate at least one adult. Please include a telephone number.
Name: _______________________________________________________ Name: _______________________________________________________

Telephone: ___________________________________________________ Telephone: ___________________________________________________

Adults NOT Authorized to Take Youth To and From Events:

Name: _______________________________________________________ Name: _______________________________________________________

Telephone: ___________________________________________________ Telephone: ___________________________________________________

680-001
2014 Printing
Part B: General Information/Health History B
High-adventure base participants:
Full name: _________________________________________ Expedition/crew No.:________________________________
or staff position:____________________________________
DOB: _________________________________________
Age:____________________________ Gender:_________________________ Height (inches):___________________________ Weight (lbs.):_____________________________

Address:_________________________________________________________________________________________________________________________________________

City:___________________________________________ State:___________________________ ZIP code:_______________ Telephone:_______________________________

Unit leader:_________________________________________________________________________________ Mobile phone:__________________________________________

Council Name/No.:___________________________________________________________________________________________________ Unit No.:_____________________

Health/Accident Insurance Company:__________________________________________________ Policy No.:____________________________________________________

! Please attach a photocopy of both sides of the insurance card. If you do not have medical insurance,
enter “none” above. !
In case of emergency, notify the person below:

Name:____________________________________________________________________________ Relationship:____________________________________________________

Address: _____________________________________________________________ Home phone:________________________ Other phone:__________________________

Alternate contact name:_____________________________________________________________ Alternate’s phone:_______________________________________________

Health History
Do you currently have or have you ever been treated for any of the following?

Yes No Condition Explain

Diabetes Last HbA1c percentage and date:

Hypertension (high blood pressure)

Adult or congenital heart disease/heart attack/chest pain
(angina)/heart murmur/coronary artery disease. Any heart
surgery or procedure. Explain all “yes” answers.
Family history of heart disease or any sudden heart-
related death of a family member before age 50.
Stroke/TIA

Asthma Last attack date:

Lung/respiratory disease

COPD

Ear/eyes/nose/sinus problems

Muscular/skeletal condition/muscle or bone issues

Head injury/concussion

Altitude sickness

Psychiatric/psychological or emotional difficulties

Behavioral/neurological disorders

Blood disorders/sickle cell disease

Fainting spells and dizziness

Kidney disease

Seizures Last seizure date:

Abdominal/stomach/digestive problems

Thyroid disease

Excessive fatigue

Obstructive sleep apnea/sleep disorders CPAP: Yes £ No £

List all surgeries and hospitalizations Last surgery date:

List any other medical conditions not covered above

680-001
2014 Printing
Part B: General Information/Health History B
High-adventure base participants:
Full name: _________________________________________ Expedition/crew No.:________________________________
or staff position:____________________________________
DOB: _________________________________________

Allergies/Medications
Are you allergic to or do you have any adverse reaction to any of the following?

Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain

Medication Plants

Food Insect bites/stings

List all medications currently used, including any over-the-counter medications.

CHECK HERE IF NO MEDICATIONS ARE ROUTINELY TAKEN. IF ADDITIONAL SPACE IS NEEDED, PLEASE
INDICATE ON A SEPARATE SHEET AND ATTACH.

Medication Dose Frequency Reason

YES NO Non-prescription medication administration is authorized with these exceptions:_______________________________________________

Administration of the above medications is approved for youth by:

_______________________________________________________________________ /________________________________________________________________________
Parent/guardian signature MD/DO, NP, or PA signature (if your state requires signature)

Bring enough medications in sufficient quantities and in the original containers. Make sure that they

! are NOT expired, including inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance
medication unless instructed to do so by your doctor. !
Immunization
The following immunizations are recommended by the BSA. Tetanus immunization is required and must have been received within the last 10 years. If you had the disease,
check the disease column and list the date. If immunized, check yes and provide the year received.

Yes No Had Disease Immunization Date(s) Please list any additional information
about your medical history:
Tetanus
_____________________________________________
Pertussis
_____________________________________________
Diphtheria
_____________________________________________
Measles/mumps/rubella

Polio _____________________________________________

Chicken Pox
DO NOT WRITE IN THIS BOX
Review for camp or special activity.

Hepatitis A Reviewed by:_____________________________________________

Hepatitis B Date:____________________________________________________

Meningitis Further approval required: Yes No

Influenza Reason:_________________________________________________

Other (i.e., HIB) Approved by:_____________________________________________

Exemption to immunizations (form required) Date:____________________________________________________

680-001
2014 Printing
Part C: Pre-Participation Physical
This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants.
C
High-adventure base participants:
Full name: _________________________________________ Expedition/crew No.:________________________________
or staff position:____________________________________
DOB: _________________________________________
You are being asked to certify that this individual has no contraindication for participation inside a

! !
Scouting experience. For individuals who will be attending a high-adventure program, including one
of the national high-adventure bases, please refer to the supplemental information on the following
pages or the form provided by your patient.

Examiner: Please fill in the following information:

Yes No Explain

Medical restrictions to participate

Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain

Medication Plants

Food Insect bites/stings

Height (inches):__________________ Weight (lbs.):__________________ BMI:__________________ Blood Pressure:__________________/__________________ Pulse:__________________

Normal Abnormal Explain Abnormalities Examiner’s Certification

I certify that I have reviewed the health history and examined this person and find
Eyes no contraindications for participation in a Scouting experience. This participant
(with noted restrictions):

Ears/nose/ True False Explain

throat
Meets height/weight requirements.

Does not have uncontrolled heart disease, asthma, or hypertension.

Lungs
Has not had an orthopedic injury, musculoskeletal problems, or
orthopedic surgery in the last six months or possesses a letter of
clearance from his or her orthopedic surgeon or treating physician.
Heart
Has no uncontrolled psychiatric disorders.

Has had no seizures in the last year.

Abdomen Does not have poorly controlled diabetes.
If less than 18 years of age and planning to scuba dive, does not have
diabetes, asthma, or seizures.
Genitalia/hernia
For high-adventure participants, I have reviewed with them the
important supplemental risk advisory provided.

Musculoskeletal
Examiner’s Signature:____________________________________ Date: ________________

Provider printed name:_________________________________________________________

Neurological
Address:_______________________________________________________________________

City:______________________________________ State:_____________ ZIP code:__________

Other
Office phone:__________________________________________________

Height/Weight Restrictions
If you exceed the maximum weight for height as explained in the following chart and your planned high-adventure activity will take you more than 30 minutes away from an
emergency vehicle/accessible roadway, you may not be allowed to participate.
Maximum weight for height:

Height (inches) Max. Weight Height (inches) Max. Weight Height (inches) Max. Weight Height (inches) Max. Weight
60 166 65 195 70 226 75 260
61 172 66 201 71 233 76 267
62 178 67 207 72 239 77 274
63 183 68 214 73 246 78 281
64 189 69 220 74 252 79 and over 295

680-001
2014 Printing
High-Adventure Risk Advisory to Philmont Scout Ranch
Health-Care Providers and Parents
Phone: 575-376-2281 Website: www.philmontscoutranch.org

Philmont Scout Ranch Experience. The Philmont Medication. Each participant who needs medication must
experience is not risk-free. Staff will instruct participants in safety bring enough medicine for the duration of the trip. Consider
measures. Be prepared to listen to and follow these measures. bringing two or three supplies of vital medication. People with
Accept responsibility for the health and safety of yourself and allergies that have resulted in severe reactions or anaphylaxis
others. Each participant must be able to carry 25 to 35 percent must bring an EpiPen that has not expired.
of their body weight while hiking 5 to 12 miles per day in an
isolated mountain wilderness ranging from 6,500 to 12,500 Immunizations. Each participant must have received a
feet in elevation over trails that are steep and rocky. Summer/ tetanus immunization within the last 10 years. Recognition will be
autumn climate includes temperatures from 30 to 100 degrees, given to the rights of those Scouts and Scouters who do not have
low humidity (10 to 30 percent), and frequent, sometimes severe, immunizations because of philosophical, political, or religious
thunderstorms. Winter climatic conditions can range from –20 to beliefs. In such a situation, the Immunization Exemption Request
60 degrees. During a Winter Adventure experience, each person form is required; it is located on the Philmont website.
will walk, ski, or snowshoe along snow-covered trails pulling
loaded toboggans or sleds for up to 3 miles—or even more on a High Blood Pressure. Upon arrival at Philmont, all adult
cross-country ski trek. participants will have their blood pressure checked. Participants
should have a blood pressure less than 140/90. People with
Risk Advisory. Philmont has an excellent health and safety hypertension (greater than 140/90) should be treated and
record and strives to minimize risks to participants by emphasizing controlled before attending Philmont, and should continue on
appropriate safety precautions. Because most participants are medications while participating. The goal of treatment should be
prepared, are conscious of risks, and take safety precautions, to lower the blood pressure to normal levels. Those individuals
they do not experience injuries. If you decide to attend Philmont, with a blood pressure consistently greater than 160/100 at
you should be physically fit, have proper clothing and equipment, Philmont may be kept off the trail until their blood pressure
be willing to follow instructions, work as a team with your crew, decreases.
and take responsibility for your own health and safety.
Seizures (Epilepsy). The seizure disorder must be
Philmont staff members are trained in first aid, CPR, and accident well-controlled by medication. A well-controlled disorder is one
prevention. They can assist the adult advisor in recognizing, in which a year has passed without a seizure. Exceptions to this
reacting to, and responding to accidents, injuries, and illnesses. guideline may be considered on an individual basis, and will
Each crew is required to have at least two members trained in be based on the specific type of seizure and likely risks to the
wilderness first aid and CPR. Response times can be affected individual/other members of the crew.
by location, terrain, weather, or other emergencies and could be
delayed for hours or even days in a wilderness setting. Diabetes Mellitus. Both the person with diabetes and
one other person in the group need to be able to recognize signs
All Philmont participants should understand potential health risks of excessively high or low blood sugar. An insulin-dependent
inherent at or above 6,700 feet in elevation in a dry Southwest person who was diagnosed or who has had a change in delivery
environment. High elevation; a physically demanding high- system (e.g., insulin pump) in the last six months is advised not
adventure program in remote mountainous areas; camping while to participate. A person with diabetes who has had frequent
being exposed to occasional severe weather conditions such hospitalizations or who has had problems with low blood sugar
as lightning, hail, flash floods, and heat; and other potential should not participate until better control of the diabetes has
problems, including injuries from tripping and falling, falls from been achieved. If an individual has been hospitalized for diabetes-
horses, heat exhaustion, and motor vehicle accidents, can related illnesses within the past year, the individual must obtain
worsen underlying medical conditions. Native wild animals such permission to participate by contacting the Philmont Health
as bears, rattlesnakes, and mountain lions usually present little Lodge at 575-376-2281.
danger if proper precautions are taken.
Asthma. Asthma must be well-controlled before participating
Guests attending Philmont Training Center conferences and at Philmont. This means: 1) the use of a rescue inhaler
family programs who are unfamiliar with the backcountry should (e.g., albuterol) less than once daily; 2) no need for a rescue
review the supplemental information available on the Philmont inhaler at night. Well-controlled asthma may include the use of
website, especially information about activities that may be new long-acting bronchodilators, inhaled steroids, or oral medications
to them. such as Singulair. You may not be allowed to participate if: 1) you
have asthma not controlled by medication; or 2) you have been
Please call Philmont at 575-376-2281 if you have any questions. hospitalized/gone to the emergency room to treat asthma in the
All participants and guests should review all materials and past six months; or 3) you have needed treatment by oral steroids
websites related to the experiences they are planning to have at (prednisone) in the past six months. You must bring an ample
Philmont Scout Ranch. supply of your medication and a spare rescue inhaler that are not
expired. At least one other member of the crew should know how
Food. If the diet described in the participant guide does not to use the rescue inhaler. Any person who has needed treatment
meet the participant’s special dietary needs, contact Philmont for asthma in the past three years must carry a rescue inhaler on
directly. Visit the Philmont Scout Ranch website for sample the trek. If you do not bring a rescue inhaler, you must buy one
menus and more information. before you will be allowed to participate.

680-001
2014 Printing
High-Adventure Risk Advisory to Philmont Scout Ranch
Health-Care Providers and Parents
Phone: 575-376-2281 Website: www.philmontscoutranch.org

Recommendations for Chronic Illnesses. Psychological and Emotional Difficulties.

Adults or youth with any of the following conditions should Parents and advisors should be aware that no high-adventure
undergo an evaluation by a physician before considering experience is designed to assist participants in overcoming
participation at Philmont. psychological or emotional problems. Experience demonstrates
that these problems frequently become worse, when a participant
1. Chest pain, myocardial infarction (heart attack) or family
is under the stress of the physical and mental challenges of a
history of heart disease in any person before age 50
remote wilderness setting. Medication must never be stopped
2. Heart surgery, including angioplasty (balloon dilation), to prior to participation and should be continued throughout the
treat blocked blood vessels or place stents entire Philmont experience.
3. Stroke or transient ischemic attacks (TIAs)
Weight Limits. Weight limit guidelines (see Part C) are
4. High blood pressure used because overweight individuals are at a greater risk for
5. Claudication (leg pain with exercise, caused by hardening of heart disease, high blood pressure, stroke, altitude illness, sleep
the arteries) problems, and injury. These guidelines are for all Scouting high-
adventure activities. Each participant’s weight must be less than
6. Diabetes the maximum acceptable limit in the weight chart. Participants
7. Smoking or excessive weight 21 years and older who exceed the maximum acceptable weight
limit for their height at the Philmont medical recheck WILL NOT
The physical exertion at Philmont may precipitate either a heart be permitted to backpack or hike at Philmont. They will be sent
attack or stroke in susceptible people. Participants with a home. For participants under 21 years of age who exceed the
history of any of the seven conditions listed above should have maximum acceptable weight for height, the Philmont staff will
a physician-supervised stress test. Even if the stress test results use their judgment to determine if the youth can participate.
are normal, the results of testing are done at lower elevations, Philmont will consider up to 20 pounds over the maximum
without backpacks, and do not guarantee safety. If the test results acceptable; however, exceptions are not made automatically and
are abnormal, the individual is advised not to participate. discussion with Philmont in advance is required for any exception.
Philmont’s telephone number is 575-376-2281. Due to rescue
Allergy or Anaphylaxis. People who have had an equipment restrictions and evacuation efforts from remote sites,
anaphylactic reaction from any cause must contact Philmont under no circumstances will any individual weighing more than
before arrival. If you are allowed to participate, you will be 295 pounds be permitted to participate in backcountry programs.
required to have appropriate treatment with you. You and at
least one other member of your crew must know how to give the Philmont Approval. Staff and/or staff physicians
treatment. If you do not bring appropriate treatment with you, you reserve the right to deny the participation of any individual on
will be required to buy it before you will be allowed to participate. the basis of a physical examination and/or medical history.
Each participant is subject to a medical recheck at Philmont.
Recent Musculoskeletal Injuries and
Orthopedic Surgery. Participants will put a great
deal of strain on their joints. Individuals who have significant
musculoskeletal problems (including back problems) or
orthopedic surgery/injuries within the last six months must have a
letter of clearance from their treating physician to be considered
for approval, and Philmont should be contacted in advance of
participation. Permission is not guaranteed. Ingrown toenails are
a common problem and must be treated 30 days prior to arrival.

680-001
2014 Printing