CADET HEALTH INFORMATION FORM

CADET HEALTH INFORMATION FORM

DANIEL BOONE HIGH SCHOOL MCJROTC
Cadet Name
Birth Date

Month Day Year
Date
Grade
Height (Feet/Inches)
Weight
Eye Color
Hair Color
Glasses(Y/N)
Please enter "Y" or "N"
Hearing Devices(Y/N)
Please enter "Y" or "N"
Physician Name
Physician Phone Number
Dentist Name
Dentist Phone Number
Medical Insurance Company
Policy
Phone
Medical Insurance Company Phone Number
Dental Insurance Company
Policy
Phone
Dental Insurance Company Phone Number
INSURANCE INFORMATION IS NOT REQUIRED, BUT MAY BE NEEDED TO OBTAIN NON-EMERGENCY CARE

Does the cadet have a documented history of or does he/she currently have any of the following:

	Yes	No
Dizziness or Fainting Spells
Frequent/Severe Headaches
Head Injury/Memory Loss
Seizures/Convulsions
Concussion
Meningitis/Encephalitis
Other neurological problems
ADD/ADHD or other learning challenges
Received Counseling of any type
Depression
Anxiety Disorder
Hearing loss or wear of hearing aid
Wear glasses/contacts
Loss of vision in either eye
Impaired vision/eye disorder
Sinusitis
Hay Fever
Food Allergies
Allergies to meds
Allergies to insect stings
Asthma
Shortness of Breath
Chronic Bronchitis
Prescribed use of an inhaler
Frequent indegestion/heartburn
Ulcers
High or low blood pressuire
Heart murmur or other cardiac issues
Jaunice, Hepatitis, or other liver ailment
Hyperglycemia/Hypoglycemia (High or Low Blood Sugar)
Diabetes
Kidney Stones or other renal disorder
Hernia
Sickle Cell trait
Neurological Problems
Thyroid Trouble or Goiter
Menstrual Disorder
Immune Deficiency Disorder
Arthritis/Rheumatism/Bursitis
Foot Trouble (Corns/Bunions/Plantar's Warts)
Flat Feet
Impaired use of arms/legs/hands/feet
Swollen or painful joints
Knee trouble
Knee or foot surgery (To Include athroscopic procedures)
Use of knee brace/orthotics/prosthetics
Bone, joint, or other deformity
Plate(s), screw(s), rod(s), pin(s) in any bone

Other Issues
Enter any other issues not listed above
Please provide an explanation for any item marked yes above (Other than the wearing of glasses/contacts):
Item #1
1st item marked yes. skip this question if not applicable
Item #2
2nd item marked yes. Skip this question if not applicable
Item #3
3rd item marked yes. Skip this question if not applicable
Item #4
4th item marked yes. Skip this question if not applicable
Is the cadet required to take medication prescribed by a physician? If so, indicate the medication by name and the disorder it is intended to treat.

Is the cadet required to take medication prescribed by a physician? If so, indicate the medication by name and the disorder it is intended to treat.
Medication #1
Skip question if not applicable
Disorder treated by medication #1
Skip question if not applicable
Medication #2
Skip question if not applicable
Disorder treated by medication #2
Skip question if not applicable
Medication #3
Skip question if not applicable
Disorder treated by medication #3
Skip question if not applicable
Medication #4
Skip question if not applicable
Disorder treated by medication #4
Skip question if not applicable
Medication #5
Skip question if not applicable
Disorder treated by medication #5
Skip question if not applicable

Is the cadet current on all immunizations required by Tennessee state law for enrollment in public Schools?
Enter "Yes" or "No"
Has the cadet had a school sports physical in the past calendar year?
Enter "Yes" or "No"
To the best of my knowledge, my child is physically qualified to fully participate in the MCJROTC program
Enter "Yes or "No"
To the best of my knowledge, my child may participate with the following limitations Requires a doctor’s letter to substantiate
Enter "Yes" or "No"