(Every 36 months)
A Class 2 record is required once every 36 months for all participants under 40 years of age. Includes any event that exceeds 72 consecutive hours where the level of activity is similar to that normally expended at home or at school, and where medical care is readily available. Examples: resident camping, backpacking, tour camping, and hiking in relatively populated areas.

Note: Some states require an annual pre-camp medical evaluation. Your BSA local council service center can advise you about the requirements in your state.

If your child has had a medical evaluation (physical examination) within the last 36 months, a copy of the results of this examination may be attached to the health history [Class I] for all participants in a camping experience lasting longer than 72 consectuive hours (3 days and nights). If a copy is not available, a physical examination (using below) must be scheduled by a licensed medical practitioner(*). A medical evaluation also is required if your child is currently under medical care, takes a prescribed medication, requires a medically prescribed diet, has had an injury or illness during the past 6 months that limited activity for a week or more, has ever lost consciousness during physical activity, or suffered a concussion from a head injury.

Name _____________________________________________ Birth date ______________________

NOTE TO LICENSED MEDICAL PRACTITIONERS(*): The person being evaluated may be attending 1 or more weeks of camp, may be sleeping on the ground, participating in strenuous activities such as hiking, boating, and vigorous group games. Please review the HEALTH HISTORY with the participant for any interim changes. Explain any "abnormal" evaluations.

PHYSICAL EXAMINATION (To be filled out by a licensed medical practitioner)

Height ____________________ Weight ________________ BP __________ / __________ Pulse ____________________

Lab: Urinalysis (dipstick) ________________________ Albumin __________________ Sugar ____________________

VISION:   Normal ___________________________ Glasses ______________________ Contacts ____________________

HEARING:  Normal __________________ Abnormal __________________ Explain _________________________________

Check Box                  N  Abn                      N  Abn                            N  Abn
   Growth development     ( ) ( )      Teeth          ( ) ( )      Genitalia            ( ) ( )
   Cardiopulmonary system ( ) ( )      Skin           ( ) ( )      Musculoskeletal      ( ) ( )
   HEENT                  ( ) ( )      Hernia         ( ) ( )      Neurobehavioral      ( ) ( )

Explain: ________________________________________________________________________________________________

Limitations

Activity restrictions ___________________________________________________________________________________
																										 
Diet restrictions _______________________________________________________________________________________

Physician

 Name ___________________________________________ (M.D./D.O./D.C./P.A./R.N.P*.) _________________________

 Signature _____________________________________________________________  Date __________________________

 Address _______________________________________________________________ Phone __________________________

 City, State, Zip _______________________________________________________________________________________

THIS FORM IS NOT INTENDED TO BE USED BY ADULTS OVER 40, BY HIGH ADVENTURE PARTICIPANTS (USE FORM NO. 34412), OR FOR NATIONAL JAMBOREE (USE FORM NSJ-34412).
BSA form 34414 Modified