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)
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.
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
Head injury, unconsciousness
Short of Breath with activity
Heart Attack, chest pain, angina
Thyroid problems (low or high)
Heart murmur, heart problems
Diabetes, high or low blood sugars
Irregular or rapid heartbeat
Blood disease, hemophilia
High or low blood pressure
Special diet, food allergies
Hepatitis or liver problems
Current bedwetting problems
ADD (Attention Deficit Disorder)
Mental illness (bipolar, other)
Depression, anxiety, suicidal
Admission to the hospital
Other chronic medical illnesses
Sleep disorder, sleep apnea
Broken bone, joint problems
CAPF 160 JUN 13 OPR/ROUTING: HS