Capf 160 Cap Member Health History Form
ADVERTISEMENT
1
2CAP 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
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
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business