OHIO 4-H PARTICIPANT/MEMBER HEALTH HISTORY
This form must be completed for each participants by the parents/guardians of minors. This information will be kept confidential and used only for the welfare of the participant.
   
DATE ________________________________ COUNTY ____________________________________
PLEASE CIRCLE:           MALE        FEMALE AGE__________ DATE OF BIRTH _______________
NAME ___________________________________________________________________________________
                    (LAST)                  (FIRST)                 (MIDDLE)
ADDRESS ________________________________________________________________________________
                         (STREET)

(CITY)

(STATE)

                           (ZIP CODE)
PHONE (HOME) ______________________________ GUARDIAN'S WORK PHONE ____________________
INCASE OF EMERGENCY, CONTACT:
PARENT NAME ______________________________                  PHONE ______________________________
CELL PHONE _________________________________                  PAGER ______________________________
OTHER PERSON ______________________________                  PHONE ______________________________
PHYSICIAN'S NAME ___________________________                  PHONE ______________________________
DENTIST'S NAME _____________________________                  PHONE ______________________________

Instructions for Medications

1.               All prescription drugs MUST be carried in the container in which they were issued (with medical orders and physician's

                  name intact), and given to the nurse/health director. Others will not be accepted.

2.               If you need over-the-counter medications not listed below, they must be in the original container and must  be stored

                   under lock and key by the nurse/health director or a responsible adult during the 4-H event.
CHECK MEDICATIONS BELOW. THAT PARTICIPANT MAY RECEIVE IF DEEMED NECESSARY:
  nonaspirin pain medication   Acetaminophen/tylenol   laxatives
  antacids   antiseptics   diarrhea medication
  Coriciden D   Robitussin Cough Syrup   adrenalin
LIST APPROXIMATE DATE IF PARTICIPANT HAS HAD OR BEEN EXPOSED TO:
CHICKEN POX ________ TUBERCULOSIS _______ MEASLES __________ MUMPS _________
WHOOPING COUGH _________ SCARLET FEVER ___________ TETANUS IMMUNIZATION _______
Date of Last Booster _________________ Date of Last Menstrual Period ________________
Operations or Serious Injuries requiring medical treatment (specify):  __________________________________________
Check below if participant is subject to:
  headaches   fainting   heart trouble   frequent colds
  constipation   convulsions   frequent sore throats   kidney trouble
  athlete's foot   sinusitis   bed wetting   sleep walking
  ear infection   epileptic seizures   home sickness   bronchitis
  cramps   diarrhea   asthma controlled (yes, no)   other please specify
Check if Participant is Allergic to:
Foods (specify) ____________________________________________________________________________
Medication: Prescription or non-prescription drugs (specify) __________________________________________
Serious Ivy, Oak, Sumac Poisoning ______________________________________________________________
Bee or Insect Stings ____________________________ Prescribed Treatment ___________________________