Medical Forms

Medical Forms

If you are under 18 years old, You will need your parent/guardian present to complete these forms
In order to complete this section, you will need to following:
- Parent/Guardian present for signatures
- Insurance card (copy front and back)
- Health and medication knowledge
- Vaccination record
- Doctors contact information
- Squadron commanders contact information (name, day, and evening phone number)
CAPF 160 CAP MEMBER HEALTH HISTORY FORM

This information in CONFIDENTIAL and for official use only. It cannot be relased to unauthorized persons. Answer all questions as accurately as possible so that the activity or encampment staff can make themselves aware of any pre-existing medical problems or conditions and be alert to help you. This form will also provide medical information in a case when you are unable to do so.
Applicant Last Name *
Applicant First Name & Middle Initial (if any)*
Grade (Rank in CAP)*
CAPID (6-digit number that starts with 1 through 6)*
Charter Number (PCR-AK-XXX)*
Date of Birth*

MonthDayYear
MM/DD/YYYY
Height*
Inches
Weight*
Lbs
Hair Color
Eye Color
Gender*
Allergies: *
List Names of medications or other Allergies (e.g. bee sting, food, plants) and types of reactions; please note food allergy details with dietary restrictions here and below, or state "no known allergies."
Do You Now Have or Have You Ever Had Any Of The Following? For any checkmarks in the boxes below, specify which condition applies (e.g., if you check "depression, anxiety, suicidal," state which condition applies to the applicant in the remarks section below). Conditions not specifically noted below having the potential to interfere with performance during the special activity or encampment should also be documented in the remarks section.
Decreased vision, glaucoma, contactsEar infections, perforationDifficulty equalizing earsHearing loss, hearing aidAllergies, nasal stuffinessAnaphylaxis, serious allergic reactionAsthma, emphysema (COPD)Ever use an inhalerShort of Breath with activityHeart Attack, chest pain, anginaHeart murmur, heart problemsCongestive heart failureIrregular or rapid heartbeatHigh or low blood pressureStomach trouble, ulcersHepatitis or liver problemsDiarrhea, constipationHernia or ruptureKidney disease or stonesProstate problems (men)Frequent urinationMenstrual cramps (women)Broken bone, joint problemsChronic or recurring injuriesActivity, mobility restrictionsUse of cane, walker, wheelchairBack or neck pain or injuryMigraine or severe headachesDizziness or fainting spellsHead injury, unconsciousnessEpilepsy or seizureStroke, paralysisThyroid problems (low or high)Diabetes, high or low blood sugarsCancer, leukemiaBlood disease, hemophiliaMotion sicknessSpecial diet, food allergiesCurrent bedwetting problemsADD (Attention Deficit Disorder)Mental illness (bipolar, other)Depression, anxiety, suicidalAdmission to the hospitalOther chronic medical illnessesSleep disorder, sleep apneaSerious Injury
For any checkmarks in the boxes above, specify which condition applies (e.g., if you check "depression, anxiety, suicidal," state which condition applies to the applicant in the remarks section below). Conditions not specifically noted above having the potential to interfere with performance during the special activity or encampment should also be documented in the remarks section.

If nothing is checked above & you have nothing additional to specify, write "N/A" in remarks
Remarks: *
Dietary Restrictions or Limitations
(List any dietary restrictions like food allergies, diabetes, gluten-free, vegetarian diets, etc.)
Past Surgical History
(List all surgeries including tonsils, ear tubes, appendix, gall bladder, hernia, hysterectomy, heart, heart catheterization, bone and joint, and all other surgeries.)
Tetanus Booster Td or TdapHepatitisPneumoniaVaricella/chickenpoxInfluenza
Date Tetanus Booster

MonthDayYear
Date
Date Hepatitis Vaccine

MonthDayYear
Date
Date Pneumonia Vaccine

MonthDayYear
Date
Date Varicella/Chickenpox Vaccine

MonthDayYear
Date
Date Influenza Vaccine

MonthDayYear
Date
Medication Information - Include supplements, over-the-counter medicines, herbals, creams, etc., or write “None”.

Medication Information

Rows	Name of Medication/Inhaler	Tablet Strength	Times Taken	Reason for Medication	Any special Dosing or Storage Instructions
1.
2.
3
4

Social History
Tobacco Use (packs per day, years smoked, smokeless tobacco use)
Occupation (student or other)
Religious Preference
CONSENT FOR MINOR CADET PARTICIPATION, MEDICATIONS, TREATMENT
I give permission for full participation in CAP programs, subject to any limitations noted herein.

My signature below evidences my consent for my child/ward to possess and self-administer the prescription medications listed above. I understand that there are legal limitations imposed on CAP senior members with regard to involuntary administration of medications to my child/ward.

In case of emergency, I understand every effort will be made to contact me. In the event I cannot be reached. I hereby give my permission to the licensed health-care practicioner selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge exams/test results and treatment provided.
Date of Signature*

MonthDayYear
Date
Parent/Guardian Name (if applicant over 18, type applicant's name)*
Parent/Guardian Signature (if applicant over 18, applicant sign here)*

Clear
- EMERGENCY INFORMATION
  
  For this section, you will need your insurance information and upload a copy of your insurance card front and back.
- Insurance/Physician Information, Emergency Contacts, Minor Consents
- Applicant's Address*
  
  Mailing Address (Number and Street)
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Applicant's Home Phone (best number to reach emergency contact)*
  Format: (000) 000-0000.
- Applicant's Cell Phone
  Format: (000) 000-0000.
- Primary Insurance Information
  
  Please attach copy of insurance cards, front and back.
  Cancelof
- Medical Insurance Company
- Policy Number
- Group Code/Number
- Co-Pay Amount
- Prescription Coverage Company
- Policy Number
- Group Code/Number
- Co-Pay Amount
- Family Physician
- Family Physician Name*
- Family Physician Phone number*
  Format: (000) 000-0000.
- Family Physician Address
  
  Mailing Address (Number and Street)
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Emergency Contact (Parent, guardian or closest relative to be notified in case of emergency)
- Emergency Contact Name*
- Relationship to Applicant*
- Emergency Contact Address
  
  Mailing Address (Number and Street)
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- (Area Code) Pager
- Emergency Contact's Cell/Mobile Phone*
  Format: (000) 000-0000.
- Emergency Contact's (Area Code) Day Phone*
  Format: (000) 000-0000.
- Emergency Contact's (Area Code) Night Phone
  Format: (000) 000-0000.
- Unit (ie Squadron) Commander Information
- Unit Commander Name and Grade (Rank)*
- Unit Name
- (Area Code) Unit Commander Day Phone*
  Format: (000) 000-0000.
- (Area Code) Unit Commander Night Phone*
  Format: (000) 000-0000.
- PERMISSION FOR PROVISION OF MINOR CADET OVER-THE-COUNTER MEDICATION
- This form may not be usable in some states due to statutes concerning who can administer medications and administration conditions. Wings with such restrictions will publish appropriate additional guidance in a supplement to CAPR 160-1.
- Over-The Counter/Non-Prescription Medications
  
  The following over-the-counter medications may be administered according to package directions by CAP senior members. Check those approved to give.
- Acetaminophen (Tylenol) for fever or painIbuprofen (Advil, Motrin) for fever or painBacitracin or Neosporin antibiotic ointment to prevent infectionHydrocortisone anti-inflammatory rash creamCalamine/Caladryl for poison ivy itch reliefAntifungal creams and sprays for treatment of fungal rashesVisine eye drops for dry, irritated eye reliefOp-Con A eye drops for allergic conjunctivitisBenadryl liquid/tabs for allergic reactionsClaritin antihistamine for seasonal allergiesRobitussin products for relief of cough and cold symptomsDelsym to suppress coughTums or Maalox for relief of stomach upsetOther
- Allergies:
  My child/ward has the above allergies or reactions to over-the-counter medications as listed above. (list type of reactions)
- Consent For Minor Cadet To Receive Over-The-Counter Medications
  
  My signature below evidences my consent for CAP senior members to provide over-the counter non-prescription medications (such as those listed above) to my child/ward if indicated in the reasonable judgment of such senior members. I understand that I will be informed if any such medications are administered.
- Signature Date*
  
  MonthDayYear
  Date
- Parent/Guardian Name (if applicant over 18, type in applicant's name)*
- Signature of Parent/Guardian (if applicant over 18, applicant sign here)*
  
  Clear
- Should be Empty:

Medical Forms

Social History

CONSENT FOR MINOR CADET PARTICIPATION, MEDICATIONS, TREATMENT

EMERGENCY INFORMATION

Insurance/Physician Information, Emergency Contacts, Minor Consents

Family Physician

PERMISSION FOR PROVISION OF MINOR CADET OVER-THE-COUNTER MEDICATION

Over-The Counter/Non-Prescription Medications