CAP MEMBER 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)
*
Grade
*
CAPID
*
Charter Number
*
Date of Birth
*
/
Month
/
Day
Year
Date
Height
*
Weight
*
Hair Color
*
Eye Color
*
Gender
*
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 below on back as well.
Do You Now Have Or Have You Ever Had Any Of The Following? Explain any yes’ in the remarks section below or attach additional sheet. 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.)
No
Yes - Decreased vision, glaucoma, contacts
No
Yes - Chronic or recurring injuries
No
Yes - Ear infections, perforation
No
Yes - Activity, mobility restrictions
No
Yes - Difficulty equalizing ears
No
Yes - Use of cane, walker, wheelchair
No
Yes - Hearing loss, hearing aid
No
Yes - Back or neck pain or injury
No
Yes - Allergies, nasal stuffiness
No
Yes - Migraine or severe headaches
No
Yes - Anaphylaxis, serious allergic reaction
No
Yes - Dizziness or fainting spells
No
Yes - Asthma, emphysema (COPD)
No
Yes - Head injury, unconsciousness
No
Yes - Ever use an inhaler
No
Yes - Epilepsy or seizure
No
Yes - Short of Breath with activity
No
Yes - Stroke, paralysis
No
Yes - Heart Attack, chest pain, angina
No
Yes - Thyroid problems (low or high)
No
Yes - Heart murmur, heart problems
No
Yes - Diabetes, high or low blood sugars
No
Yes - Congestive heart failure
No
Yes - Cancer, leukemia
No
Yes - Irregular or rapid heartbeat
No
Yes - Blood disease, hemophilia
No
High or low blood pressure
No
Yes - Motion sickness
No
Yes - Stomach trouble, ulcers
No
Yes - Special diet, food allergies
No
Yes - Hepatitis or liver problems
No
Yes - Current bedwetting problems
No
Yes - Diarrhea, constipation
No
Yes - ADD (Attention Deficit Disorder)
No
Yes - Hernia or rupture
No
Yes - Mental illness (bipolar, other)
No
Yes - Kidney disease or stones
No
Yes - Depression, anxiety, suicidal
No
Yes - Prostate problems (men)
No
Yes - Admission to the hospital
No
Yes - Frequent urination
No
Yes - Other chronic medical illnesses
No
Yes - Menstrual cramps (women)
No
Yes - Sleep disorder, sleep apnea
No
Yes - Broken bone, joint problems
No
Yes - Serious 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)
Tetanus Booster
No
Td or Tdap Date:
/
Month
/
Day
Year
Date
Hepatitis Vaccine
No
Date
-
Month
-
Day
Year
Date
Pneumonia Vaccine
No
Date:
/
Month
/
Day
Year
Date
Varicella Immunization/chickenpox
No
Date:
/
Month
/
Day
Year
Date
Influenza Vaccine
No
Date:
/
Month
/
Day
Year
Date
Medication Information - Include supplements, over-the-counter medicines, herbals, creams, etc., or write “None".
Name of Medication/ Inhaler
Tablet Strength
Times taken per day
Reason for Medication
Any Special 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 (Attach additional sheet if needed)
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 OF PARENT/GUARDIAN (Please Sign PDF Copy of Form)
Parent Email (person who will be signing form)
example@example.com
Date
*
-
Month
-
Day
Year
Date
CAP Form 160
A PDF copy of the filled-out form will be sent to the email, please print and sign and bring to encampment. An electronic copy of this will be maintained in a HIPPA compliant database. Please contact us if any information changes.
Submit
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