Cap Form 31 - Application For Cap Encampment Or Special Activity Page 3
ADVERTISEMENT
1
2
3
4MEDICAL INFORMATION - TO BE COMPLETED BY ALL APPLICANTS
This information is for Official Use Only and will not be released to unauthorized persons. Answer all questions as accurately as possible so that special activity or encampment staff can
make themselves aware of any pre-existing medical problems or conditions and be alert to help you.
HAVE YOU EVER HAD AN FAA OR OTHER FLIGHT PHYSICAL DENIED, SUSPENDED, OR REVOKED?
NO
YES (Give the date and reason in the remarks section.)
DO YOU CURRENTLY USE ANY MEDICATION? (Including eye drops)
NO
YES (List any medication taken and the reason in the remarks section.)
HAVE YOU HAD OR BEEN INVOLVED IN AN ACCIDENT IN THE PAST 2 YEARS?
NO
YES (Explain the extent of your injuries and treatment required in the remarks
section.)
HAVE YOU HAD OR HAVE NOW ANY OF THE FOLLOWING? (If yes is answered on any items, please explain why in the remarks section with dates and physician(s) consulted (if any).
Items 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
Frequent or severe headaches
NO
YES Ear infections
NO
YES Chronic diseases like Diabetes or Bronchitis
NO
YES
Dizziness or fainting spells
NO
YES Rupture
NO
YES Girls only - Menstrual cramps
NO
YES
Unconsciousness for any reason
NO
YES Positive TB skin test
NO
YES Other illness or accidents
NO
YES
Eye trouble, excluding glasses
NO
YES Epilepsy or fits
NO
YES Military rejection or medical discharge
NO
YES
Hay fever
NO
YES Kidney stones or blood in urine
NO
YES Rejection for life insurance
NO
YES
Sugar or albumin in urine
NO
YES Motion sickness
NO
YES Admission to hospital
NO
YES
Heart trouble
NO
YES Nervous trouble of any sort
NO
YES Record of traffic convictions
NO
YES
High or low blood pressure
NO
YES Any known allergies
NO
YES Record of other convictions
NO
YES
Stomach trouble
NO
YES Any drug or narcotic habit
NO
YES Attempted suicide
NO
YES
Asthma
NO
YES Chronic or recurring injuries
NO
YES Medical treatment within the past 5 years other
than regular office visits or physicals
IMMUNIZATIONS
FAMILIY PHYSICIAN (Name, address, and phone number)
INSURANCE INFORMATION
Medical
Liability
Company
Company
Policy Number
Policy Number
EMERGENCY ADDRESSEE - PARENT, GUARDIAN, OR CLOSEST RELATIVE TO BE NOTIFIED IN CASE OF EMERGENCY
Name
Relationship
Address
Day Telephone
Night Telephone
REMARKS
CAP FORM 31 JUN 07 PAGE 3/4
CONTINUE ON TO LAST PAGE
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business