Fillable Form BSA Medical Form

What is a BSA Medical Form?

A Boy Scouts of America (BSA) Medical Form is a document that provides essential medical information about a scout to their leaders and medical professionals. The form is designed to ensure that scouts have the necessary medical clearance to participate in BSA activities safely, and asks for information on the scout’s medical history and conditions.

How do I fill out a BSA Medical Form?

BSA Medical Forms require information about a scout’s medical history. Because of this, it is highly recommended that you consult a healthcare provider that can provide more accurate details about the scout’s health information.

Part A: Informed Consent, Release Agreement, and Authorization

Full Name and Date of Birth

Enter the scout’s full name and date of birth.

High-adventure Base Participants

Enter the expedition or crew number, or staff position, of the person that is reviewing this form.

Informed Consent

This section serves to inform parents and guardians of the activities that the BSA will hold. Check the box provided if you do not want the scout to use a BB device, then enter any restrictions on what the scout may or may not participate in in the space provided. If no restrictions are needed, check the box labeled “none” instead.

Participant’s Signature

Have the scout sign the form in the space provided, then enter the date that the form was signed. If the scout is still a minor, have their parent or guardian sign the form in the space provided then enter the date that the form was signed.

Authorized Adults

For scouts that are still minors, enter the full legal name and phone number of each adult person that is authorized to take the scout to and from events. If more space is required, attach a separate sheet of paper and label it accordingly.

Unauthorized Adults

If there are any particular adult persons that are specifically not allowed to bring the scout to and from events, enter their name and phone number. If more space is required, attach a separate sheet of paper and label it accordingly.

Part B1: General Information/Health History

Full Name and Date of Birth

Enter the scout’s full name and date of birth.

High-adventure Base Participants

Enter the expedition or crew number, or staff position, of the person that is reviewing this form.

Age

Enter the scout’s age.

Gender

Enter the scout’s gender.

Height (inches)

Enter the scout’s height in inches.

Weight (lbs)

Enter the scout’s weight in pounds.

Address

Enter the scout’s home address.

City

Enter the city that the scout resides in.

State

Enter the state that the scout resides in.

ZIP Code

Enter the scout’s ZIP code.

Phone

Enter the scout’s primary phone number.

Unit Leader

Enter the leader of the unit the scout is in.

Unit Leader’s Mobile Number

Enter the unit leader’s mobile number.

Council Name or Number

Enter the name or number of the council.

Unit Number

Enter the number of the scout’s troop or unit.

Health/Accident Insurance Company

Enter the name of the scout’s insurance company, if they have insurance.

Policy Number

Enter the policy number of the scout’s insurance policy. Then attach a photocopy of both sides of the scout’s insurance card. If the scout does not have medical insurance, enter “None” in the spaces for insurance information.

Emergency Contact Details

Name of Emergency Contact

Enter the emergency contact’s full legal name.

Relationship

Enter the emergency contact’s relationship to the scout.

Address

Enter the emergency contact’s address information.

Home Phone

Enter the emergency contact’s home phone number.

Other Phone

Enter any other active phone number the emergency contact has, if any.

Alternate Contact Name

In the event that the primary emergency contact is unavailable, enter the name of the person to be contacted.

Alternate’s Phone

Enter the alternate emergency contact’s phone number.

Health History

For each of the following conditions, check “Yes” if the scout has ever been treated for that condition, and “No” if not. Then, enter a short explanation or description of the treatment taken by the scout. Some conditions may require more specific details regarding the description of their treatment, so make sure to read each entry carefully so that you can be sure you are entering the correct information.

• Diabetes
• Hypertension
• Adult or Congenital Heart Disease/Heart Attack/Chest Pain/Heart Murmur/Coronary Artery Disease (explain the treatment for all of the ones that the scout was treated for)
• Family History of Heart Disease
• Stroke/TIA
• Asthma
• Lung/Respiratory Disease
• COPD
• Ear/Eyes/Nose/Sinus problems
• Muscular/Skeletal condition/Muscle or Bone issues
• Head Injury/Concussion/TBI
• Altitude Sickness
• Psychiatric/Psychological or Emotional Difficulties
• Neurological/Behavioral Disorders
• Blood Disorders/Sickle Cell Disease
• Fainting Spells and Dizziness
• Kidney Disease
• Seizures or Epilepsy
• Abdominal/Stomach/Digestive Problems
• Thyroid Disease
• Skin Issues
• Obstructive Sleep Apnea/Sleep Disorders
• Any Surgeries and Hospitalizations (List all surgeries and hospitalizations of the scout, then enter a short description of each one)
• Any other medical conditions not covered above

If more space is required, you may use an appropriately labeled sheet of paper and attach it to this form. It may also be beneficial to attach copies of documents like doctor’s notes or any other documentation of the treatment undergone by the scout for any given condition.

Part B2: General Information/Health History

Full Name and Date of Birth

Enter the scout’s full name and date of birth.

High-adventure Base Participants

Enter the expedition or crew number, or staff position, of the person that is reviewing this form.

Allergies/Medications

Epinephrine Autoinjector/Asthma Rescue Inhaler

Check the box that indicates whether or not the scout has an epinephrine autoinjector and/or an asthma rescue inhaler. Then, if you checked yes for both or either, enter the expiration date of the medication in the space provided.

Allergies

Check “Yes” for each of the following that the scout is allergic to, and “No” for each that they are not. Then enter a brief explanation of the specifics of their allergy.

• Medication
• Food
• Plants
• Insect Bites/Stings

Medications Currently Used

In the table provided, list all of the medications that the scout uses at present, as well as at what dose, how frequently, and for what reason. If no medications are currently being taken, check the box labeled “No medications are routinely taken”. If more space is required, check the box labeled “If additional space is needed, please list on a separate sheet and attach” and attach said appropriately labeled sheet to this form.

Non-Prescription Medication

If administering non-prescription medication is allowed for the scout, check “Yes” and enter any exceptions to the non-prescription medication the scout is allowed to use. Otherwise, check “No”.

Parent and Healthcare Officer Signature

Have the scout’s parent/guardian and doctor or other healthcare provider sign the form in the space provided.

Immunization

For each of the following diseases, check “Yes” if the patient has been immunized/vaccinated against the disease. Check the box provided if the student has ever contracted that disease. Then, if the patient was immunized/vaccinated, enter the date of immunization in the space provided.

• Tetanus
• Pertussis
• Diphtheria
• Measles/Mumps/Rubella
• Polio
• Chicken Pox
• Hepatitis A
• Hepatitis B
• Meningitis
• Influenza
• Other
• Exemption to Immunizations (a separate form explaining this exemption will be required)

Additional Info on Medical History

Enter any additional relevant information about the scout’s medical history in the space provided.

For Camp or Special Activity (To be filled out by the person reviewing this form after it is submitted)

Reviewed By

Enter the name of the person reviewing this form.

Date

Enter the date that this form was reviewed.

Further Approval Required

If further approval is required for this form, check “Yes”. Otherwise, check “No”.

Reason

Enter the reason why the form requires further approval or not.

Approved By

Enter the name of the person that approved this form.

Date

Enter the date that the form was approved.

Part C: Pre-Participation Physical

Full Name and Date of Birth

Enter the scout’s full name and date of birth.

High-adventure Base Participants

Enter the expedition or crew number, or staff position, of the person that is reviewing this form.

Medical Restrictions to Participate

If the scout has any medical restriction to participate, check “Yes” and enter a brief explanation in the space provided. Otherwise, check “No”.

Allergies or Reactions

Check “Yes” for each of the following that the scout is allergic to or has a reaction to, and “No” for each that they do not. Then enter a brief explanation of the specifics of their allergy or reaction.

• Medication
• Food
• Plants
• Insect Bites/Stings

Height (Inches)

Enter the scout’s height in inches.

Weight (lbs)

Enter the scout’s weight in pounds.

BMI

Enter the scout’s Body Mass index (BMI).

Blood Pressure

Enter the scout’s blood pressure.

Pulse

Enter the scout’s pulse rate in beats per minute (bpm).

Observations

For each of the following, check “Normal” if the scout expresses no abnormalities in the concerned area, and “Abnormal” if any abnormalities are observed. If “Abnormal” was checked, enter a brief explanation of what the abnormalities observed are.

• Eyes
• Ears/Nose/Throat
• Lungs
• Heart
• Abdomen
• Genitalia/Hernia
• Musculoskeletal
• Neurological
• Skin Issues
• Other

Examiner’s Certification

For each of the following conditions, check “True” if they apply to the scout and “False” if they do not.

• Meets height/weight requirements.
• Has no uncontrolled heart disease, lung disease, or hypertension.
• Has not had an orthopedic injury, musculoskeletal problems or orthopedic surgery in the last six months, or possesses a letter of clearance from their orthopedic surgeon or treating physician.
• Has no uncontrolled psychiatric disorders.
• Has had no seizures in the last year.
• Does not have poorly controlled diabetes.
• If planning to scuba dive, does not have diabetes, asthma, or seizures.

Examiner’s Signature

Have the examiner sign the form in the space provided, then enter the date that the form was signed.

Examiner’s Name

Enter the examiner’s full legal name.

Address

Enter the examiner’s address information.

City

Enter the examiner’s city of residence or operation.

State

Enter the state that the examiner resides in or operates from.

ZIP code

Enter the examiner’s ZIP code.

Office Phone

Enter the examiner’s office phone number.

Frequently Asked Questions (FAQs)

Who should complete the BSA Medical Form?

The BSA Medical Form should be completed by the scout's parent or guardian with input from their healthcare provider.

Is there a specific healthcare provider who needs to complete or help complete Part B of the form?

Not in particular. It is, however, preferable that the healthcare provider be the scout’s primary physician, such as a family doctor or similar, as information about the scout’s medical history and current health will be needed.

How often should a scout update their BSA Medical Form?

The BSA Medical Form should be updated annually or when there is a significant change in the scout's medical condition.

Can a scout participate in BSA activities without a completed BSA Medical Form?

No, a scout cannot participate in BSA activities without a completed BSA Medical Form.

Are there any age restrictions for completing the BSA Medical Form?

No, there are no age restrictions for completing the BSA Medical Form.

What should a scout do if they have a medical condition that may affect their participation in BSA activities?

A scout with a medical condition that may affect their participation in BSA activities should discuss their condition with their healthcare provider and provide any necessary information on the BSA Medical Form. They should then discuss the matter with their scoutmaster, troop leader, or any other relevant authority.

What should a scout do if they are taking medication while on a BSA activity?

A scout who is taking medication while on a BSA activity should inform their adult leader and provide any necessary information on the BSA Medical Form.

Can a scout be denied participation in a BSA activity based on their medical condition?

Yes. A scout can be denied participation in a BSA activity if their medical condition poses a safety risk to themselves or others and cannot be accommodated.

What happens if a scout is injured or becomes ill during a BSA activity?

If a scout is injured or becomes ill during a BSA activity, the adult leader in charge will assess the situation and provide any necessary first aid or medical care. The scout's BSA Medical Form will be consulted to ensure that any preexisting medical conditions are taken into account.

Are there any fees associated with completing the BSA Medical Form?

No, there are no fees associated with completing the BSA Medical Form.

Can a scout's medical information be kept confidential?

Yes, a scout's medical information is kept confidential and is only shared with BSA leaders and medical professionals who have a need to know.

Is the BSA Medical Form required for all types of BSA activities?

Yes, the BSA Medical Form is required for all types of BSA activities.

What should a scout do if they lose their BSA Medical Form?

A scout who loses their BSA Medical Form should contact their healthcare provider and complete a new form.

Can a BSA Medical Form be filed and submitted electronically?

Yes, the BSA Medical Form can be completed electronically as long as the completed form is printed and signed by the scout's healthcare provider.

Can a scout participate in BSA activities if they have a disability?

Yes, scouts with disabilities can participate in BSA activities as long as their condition can be accommodated and does not pose a safety risk to themselves or others.

What accommodations can be made for scouts with disabilities?

Accommodations for scouts with disabilities can include modifying activities, providing additional supervision, and making physical accommodations. These accommodations will be prepared once the necessary authority is informed of the scout’s condition or disability.

Are there any specific rules or guidelines for scouts with allergies?

Yes, scouts with allergies should inform their troop leaders of their allergy and any necessary accommodations, such as carrying an EpiPen. Troop leaders should also be aware of any food allergies and make accommodations as needed.