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
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.)
If “Yes” is marked in an item with multiple choices, please circle which problem applies.
No Yes
Decreased vision, glaucoma, contacts
Chronic or recurring injuries
Ear infections, perforation
Activity, mobility restrictions
Difficulty equalizing ears
Use of cane, walker, wheelchair
Hearing loss, hearing aid
Back or neck pain or injury
Allergies, nasal stuffiness
Migraine or severe headaches
Anaphylaxis, serious allergic reaction
Dizziness or fainting spells
Asthma, emphysema (COPD)
Head injury, unconsciousness
Ever use an inhaler
Epilepsy or seizure
Short of Breath with activity
Stroke, paralysis
Heart Attack, chest pain, angina
Thyroid problems (low or high)
Heart murmur, heart problems
Diabetes, high or low blood sugars
Congestive heart failure
Cancer, leukemia
Irregular or rapid heartbeat
Blood disease, hemophilia
High or low blood pressure
Motion sickness
Stomach trouble, ulcers
Special diet, food allergies
Hepatitis or liver problems
Current bedwetting problems
Diarrhea, constipation
ADD (Attention Deficit Disorder)
Hernia or rupture
Mental illness (bipolar, other)
Kidney disease or stones
Depression, anxiety, suicidal
Prostate problems (men)
Admission to the hospital
Frequent urination
Other chronic medical illnesses
Menstrual cramps (women)
Sleep disorder, sleep apnea
Broken bone, joint problems
Serious Injury
CAPF 160 JUN 13 OPR/ROUTING: HS
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.)
Date Tetanus
Booster
Hepatitis Vaccine
Pneumonia
Vaccine
Varicella Immuni-
zation/chickenpox
Influenza Vaccine
No Td or Tdap
No
No
No
No
Date:
Date:
Date:
Date:
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.
___________________________ ________________________________________________________________________________________________________
DATE SIGNATURE OF PARENT/GUARDIAN
CAP Form 160 Reverse