LESA South 2024 Medical Forms (18+)

Medical Forms (18+)
In order to complete this section, you will need to following:
- 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.
Last Name
First Name
Email
example@example.com
Membership Type
Grade
CAPID
Charter Number (SWR-TX-XXX)
Group
Date of Birth

MonthDayYear
MM/DD/YYYY
Height
Inches
Weight
Lbs
Hair Color
Eye Color
Gender
Allergies:
List Names of medications or other Allergies (ie bee sting, food plants) and types of reactions; please note food allergy details with dietary restrictions.
Do You Now Have or Have You Ever Had Any Of The Following? Explain any marks in the remark section below. Conditions not specifically noted below having the potential to interfere with performance during the special activity or encampment should be documented in the remarks section.
Checking box indicates YES Have/Had

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
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.)
Vaccinations NOT received

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

	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
Remarks:
CONSENT FOR MINOR CADET PARTICIPATION, MEDICATIONS, TREATMENT
Date

MonthDayYear
Date
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.
Name
Participant
- 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
- Address
  
  Mailing Address (Number and Street)
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- (Area Code) Home Phone
- (Area Code) Cell Phone
- 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
- Name
- Phone number
- 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)
- Name
- Relationship to Applicant
- Address
  
  Mailing Address (Number and Street)
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- (Area Code) Pager
- (Area Code) Cell/Mobile Phone
- (Area Code) Day Phone
- (Area Code) Night Phone
- Unit Commander Information
- Unit Commander Name and Grade
- Unit Name
- (Area Code) Unit Commander Day Phone
- (Area Code) Unit Commander Night Phone
- I am over 18 years old and of sound mind to make good decisions regarding administering over-the-counter medications.
- Date
  
  MonthDayYear
  Date
- Should be Empty:

Medical Forms (18+)

Social History

CONSENT FOR MINOR CADET PARTICIPATION, MEDICATIONS, TREATMENT

EMERGENCY INFORMATION

Insurance/Physician Information, Emergency Contacts

Family Physician