REPORT OF MEDICAL HISTORY
PLEASE COMPLETE THIS BEFORE GOING TO YOUR PHYSICIAN FOR EXAMINATION
Applicant's Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DATE OF BIRTH
*
/
Month
/
Day
Year
Social Security Number
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
*
example@example.com
Proof of Meningococcal Meningitis Vaccination (only for applicants age 21 and younger)
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MEDICAL HISTORY:
Please check the box next to any symptom or condition listed below that applies to you:
Abdominal Pain, frequent
Decreased Hearing
Irregular Pulse
Rheumatic Fever
Allergies/Hay Fever
Depression
Kidney Infection
Scarlet Fever
Anemia
Diabetes
Leg Pains/Cramps
Seizures/Convulstions
Anxiety/Nervousness
Difficulty Swallowing
Loss of Appetite
Shortness of Breath
Arthritis
Diverticulitis
Measles
Sinus Problems
Asthma
Ear Infections, frequent
Mental Illness
Sleeping Difficulties
Back-Pain, recurrent
Eye Infections, frequent
Mumps
Sore Throat, frequent
Bladder Infection
Fainting Spells
Muscle Weakness
Stroke
Blood in Urine
Fatigue, chronic
Nausea/Vomiting, persistent
Swollen Arteries
Bloody Bowel Movements
Gallbladder Disease
Nose Bleeds, recurrent
Thyroid Disease
Bone Fracture
Glaucoma
Numbness/Tingling
Tremor
Bronchitis
Gout
Palpitations
Tuberculosis
Cancer
Headaches, frequent
Phlebitis
Ulcers
Change in bowel habits, recent
Headaches, migraines
Phobias
Urethral Discharge
Chest Pain
Heart Murmor
Pneumonia/Pleurisy
Urination at night
Chicken Pox
Hemorrhoids
Polio
Urine infection
Constipation, frequent
Hepatitis
Psoriasis
Varicose Veins
Corrective Lenses
High Blood Pressure
Rashes
Venereal Disease
Indigestion/Heartburn
Weight Loss, recent
Other
I attest that I was born a biological male.
List any medication that you take regularly:
List any know drug allergies:
Do you smoke?
Yes
No
If yes, how many packs per day:
Do you have a history of alcohol abuse?
Yes
No
If yes, how long?
Do you have a history of drug abuse?
Yes
No
If so, please list drugs:
How long have you been off them?
Has your physical activity been restricted during the past five years?
Yes
No
If Yes, please explain:
Have you received treatment or counseling for any nervous condition, personality or character disorders, or emotional problems?
Yes
No
If Yes, please explain:
Have you been hospitalized for any illness or injury not already mentioned above?
Yes
No
If Yes, please explain:
Have you been or are you now under a physician's care for an extended period of time?
Yes
No
If Yes, please explain:
Are you currently on any form of medication?
Yes
No
If Yes, please explain:
Have you been rejected for or discharged from military service because of physical, emotional, or other reasons?
Yes
No
If Yes, please explain:
Do you have any questions in regards to your health, family history, or other matters which you would like to discuss?
Yes
No
If Yes, please explain:
Do you have a regular physician?
Yes
No
Physician's name
First Name
Last Name
Physician's address
Street Address
Street Address Line 2
City / State / Zip Code
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
FAMILY MEDICAL HISTORY
If a blood relative (parent, sibling, uncle, aunt or grandparent) has had any of the following diseases or conditions, list their relationship to you next to the condition.
Rows
Relationship to you
Tuberculosis
Stroke
Migraines
Mental Illness
Epilepsy
Diabetes
Heart Attack
Rows
Relationship to you
Cancer
Arthritis
Gout
Kidney Disease
Glaucoma
Allergy
Hypertension
I hereby certify that the above information is true and complete to the best of my knowledge
Applicant's signature
*
Date
*
/
Month
/
Day
Year
Date
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