Health History Form
This information is CONFIDENTIAL and for official use only. It cannot be released 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.
Name (Last, First, Middle)
*
CAP Grade
*
Please Select
C/Amn
C/A1C
C/SrA
C/SSgt
C/TSgt
C/MSgt
C/SMSgt
C/CMSgt
C/2d Lt
C/1st Lt
C/Capt
C/Maj
C/Lt Col
C/Col
Senior Member
SSgt
TSgt
MSgt
SMSgt
CMSgt
2d Lt
1st Lt
Capt
Maj
Lt Col
Col
Brig Gen
Maj Gen
CAP ID
*
Charter Number
*
Date of Birth
*
/
Month
/
Day
Year
MM/DD/YYYY
Height (inches)
*
Enter height in total inches (example - 5"4' should be entered as 64)
Weight (lbs)
*
Hair Color
Eye Color
Gender
*
Please Select
Male
Female
Allergies
*
List Names of Medication or Other Allergies (i.e., bee sting, food, plants) and types of reactions; please note food allergy details with dietary restrictions as well. Type "N/A" if none.
Do You Now Have Or Have You Ever Had Any Of The Following?
Explain any yes’ in the remarks 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.
Decreased vision, glaucoma, contacts
*
No
Yes
Ear infections, perforation
*
No
Yes
Difficulty equalizing ears
*
No
Yes
Hearing loss, hearing aid
*
No
Yes
Allergies, nasal stuffiness
*
No
Yes
Anaphylaxis, serious allergic reaction
*
No
Yes
Asthma, emphysema
*
No
Yes
Ever use an inhaler
*
No
Yes
Short of Breath with activity
*
No
Yes
Heart Attack, chest pain, angina
*
No
Yes
Heart murmur, heart problems
*
No
Yes
Congestive heart failure
*
No
Yes
Irregular or rapid heartbeat
*
No
Yes
High or low blood pressure
*
No
Yes
Stomach trouble, ulcers
*
No
Yes
Hepatitis or liver problems
*
No
Yes
Diarrhea, constipation
*
No
Yes
Hernia or rupture
*
No
Yes
Kidney disease or stones
*
No
Yes
Prostate problems (men)
*
No
Yes
Frequent urination
*
No
Yes
Menstrual cramps (women)
*
No
Yes
Broken bone, joint problems
*
No
Yes
Chronic or recurring injuries
*
No
Yes
Activity, mobility restrictions
*
No
Yes
Use of cane, walker, wheelchair
*
No
Yes
Back or neck pain or injury
*
No
Yes
Migraine or severe headaches
*
No
Yes
Dizziness or fainting spells
*
No
Yes
Head injury, unconsciousness
*
No
Yes
Epilepsy or seizure
*
No
Yes
Stroke, paralysis
*
No
Yes
Thyroid problems (low or high)
*
No
Yes
Diabetes, high or low blood sugars
*
No
Yes
Cancer, leukemia
*
No
Yes
Blood disease, hemophilia
*
No
Yes
Motion sickness
*
No
Yes
Special diet, food allergies
*
No
Yes
Current bedwetting problems
*
No
Yes
ADD (Attention Deficit Disorder)
*
No
Yes
Mental illness (bipolar, other)
*
No
Yes
Depression, anxiety, suicidal
*
No
Yes
Admission to the hospital
*
No
Yes
Other chronic medical illnesses
*
No
Yes
Sleep disorder, sleep apnea
*
No
Yes
Serious Injury
*
No
Yes
Dietary Restrictions or Limitations
*
List any dietary restrictions like food allergies, diabetes, gluten-free, vegetarian diets, etc. Type "N/A" if none.
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. Type "N/A" if none.
Tetanus Booster
*
No
Yes - Enter Date
Hepatitis Vaccine
*
No
Yes - Enter Date
Pneumonia Vaccine
*
No
Yes - Enter Date
Chickenpox (Varicella) Immunization
*
No
Yes - Enter Date
Influenza Vaccine
*
No
Yes - Enter Date
Medication Information - Include supplements, over-the-counter medicines, herbals, creams, etc., or write “None”.
Name of Medication/Inhaler
Strength
Times Taken per Day
Reason for Medication
Dosing or Storage Instructions (i.e. as needed, with meals, must be refrigerated, etc)
1.
2.
3.
4.
Social History
Tobacco Use
Packs per day, years smoked, smokeless tobacco use
Occupation
Student or Other
Religious Preference
Remarks
*
Use this section to explain any "Yes" checkmarks from the medical history section above. Type N/A if none.
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 the involuntary administration of medications to my child/ward. (Cross out if permission is denied).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 practitioner 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 exam/test results and treatment provided.
Signature Date
*
/
Month
/
Day
Year
Date
Signature of Participant or Parent/Guardian
*
Preview PDF
Submit
Should be Empty: