Medical History (If you answer “yes,” please provide explanation in block 41.)
1. Eye trouble (to include vision loss, cataract, glaucoma, keratoconus, corneal ectasia, retinal detachment)?
2. Surgery to improve vision (PRK, LASIK, LASEC, RK, intraocular lens implant, cross linking)?
3. Color vision deficiency?
4. Ear trouble (to include perforated ear drum, tubes in ears, or other ENT surgery)?
5. Loss of balance or vertigo?
6. Hearing loss or use of a hearing aid?
7. Nose, throat, or sinus trouble (to include sinusitis, abscess, surgery on nose, sinuses or throat)?
8. Orthodontic treatment? (if "yes", include completion or projected date of completion in block 41)
9a. Tooth or gum trouble (excluding cavities)?
9b. Date of last dental exam:
10. Breathing trouble (to include asthma, wheezing, shortness of breath, chronic cough, use of inhaler, collapsed lung)?
11. Cardiac trouble (to include chest pain, palpitations, heart valve problems, surgery, high or low blood pressure)?
12. Gastrointestinal trouble (to include celiac disease, irritable bowel syndrome, ulcer, reflux, esophagitis, gallstones, hernia, or
13. Inflammatory bowel disease (to include Ulcerative colitis or Crohn's disease)?
14a. Gynecologic trouble (including endometriosis, polycystic ovarian disease, abnormal pap smear)? (females only)
14b. Date of last menstrual period (females only):
14c. Date of Last PAP smear (females only):
15. Testicular or prostate trouble? (males only)
16. Orthopedic problems of the back or neck?
17. Orthopedic problems of the upper extremities (fracture, dislocation, sprain, surgery)?
18. Orthopedic problems of the lower extremities (fracture, dislocation, sprain, surgery)?
19. Vascular trouble (Raynaud's disease, blood clot or deep venous thrombosis, high blood pressure)?
20. Skin trouble (to include psoriasis, eczema, atopic dermatitis, severe acne)?
21. Prescribed systemic retinoid medications (i.e.: Accutane)? (List date completed or projected completion date in block 41.)
22. Blood disorders (anemia, thrombocytopenia, bleeding disorders, disorder of the spleen)?
23. Allergic reaction to food, medications, insects?
24. A positive PPD or been treated for tuberculosis?
25. Car, train, sea, or air sickness that required prescription medication or avoidance of travel?
26. Endocrine disorders (including diabetes, thyroid, osteoporosis)?
27. Head injury, memory loss, amnesia?
28. Neurologic trouble (including dizziness, fainting spell, seizure, paralysis)?
NROTC Preparatory Program