Cadet Consent For Medical Treatment Page 2
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CADET MEDICAL HISTORY
CADET’S NAME _____________________________________________________________________________________
LIST THE MEDICATIONS, AND VITAMINS THAT YOUR CADET IS CURRENTLY TAKING (include dose and schedule): ____________________________
__________________________________________________________________________________________________________________________
Prescribing Doctor ______________________________________________________Doctor’s Phone #_____________________________________
MEDICAL HISTORY Does your Cadet HAVE or has your Cadet EVER HAD any of the following conditions: (please check)
YES
NO
YES
NO
YES
NO
Abdominal Pain (chronic)
Fatigue (chronic)
Neurological Disease
ADD/ADHD
Fracture
Neuromuscular Disorder
Alcohol/Drug use/addiction
Gastrointestinal Disorders
Orthopedic Conditions
Anemia/Thalassemia
Guillain Barre
Pneumonia
Appendicitis/Appendectomy
Gynecological Issues (females)
Psychiatric Treatment
Asthma/Wheezing
Head Injury/Concussion
Psychological Counseling
Bronchitis
Headaches (recurrent)
Rubella/German Measles
Bursitis
Hearing Disorders
Seizures
Cancer
Heart Disease/Murmur/Palpitations
Sickle Cell Anemia/Family History
Chicken Pox
Heat Related Illness
Sinus Infections (recurrent)
Concussion/Brain Injury
Hepatitis/Jaundice
Skin Disorders
Congenital Abnormality
Hernia
Spleen Injury/Splenectomy
Dental Issues/Surgery
High Blood Pressure
Stinger/Burner
Depression
Immune Disease
Tendonitis
Diabetes
Indigestion
Testicular Pain/Issues (males)
Dislocation
Kidney Disease
Tobacco Use
Dizziness/ Fainting
Measles (Rubeola)
Tuberculosis
Ear Infections (chronic)
Migraines
Ulcer
Eating Disorders
Mononucleosis
Urinary Tract Infection
Enuresis (bedwetting)
Mumps
Vision Problems
Explain any YES answers _____________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
YES
NO
MEDICATION ALLERGIES? List ________________________________________________________________________________________________
Any other allergies? List _________________________________________________________________________________________________________
An adverse reaction to a vaccination? Explain _________________________________________________________________________________________
Positive TB test reaction. (Chest X-Ray must be provided) Explain ________________________________________________________________________
Prior hospital admissions? Explain__________________________________________________________________________________________________
Any type of surgery? Explain ______________________________________________________________________________________________________
Any serious illness/injury without hospitalization? Explain _____________________________________________________________________________
Has anyone in the family died of cardiac problems before the age of 50? Relationship to Cadet __________________________________________________
Family History of Marfan Syndrome? Relationship to Cadet _____________________________________________________________________________
Needed to use an Inhaler? How often?________________________________________________________________________________________________
Any unexplained loss of consciousness? Explain ______________________________________________________________________________________
Significant absenteeism from school because of illness? Explain __________________________________________________________________________
Restriction for sports participation or physical activity due to illness or injury within the past 3 years? Explain ______________________________________
Treatment or counseling for an emotional/psychiatric problem within 3 years? Explain _________________________________________________________
Any physical or emotional disability? Explain ________________________________________________________________________________________
Any condition requiring a specialized physical education program? Explain_________________________________________________________________
Any other significant past medical history? Explain
___________________________________
________________________________
PARENT OR GUARDIAN’S SIGNATURE
CADET SIGNATURE (if age 18 or older)
__________________________________________
______________________________________
DATE
DATE
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