Cnet Form 1533/106 Njrotc Standard Release Form Page 3
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3NJROTC HEALTH RISK SCREENING QUESTIONNAIRE
Cadet Name:_____________________________________________________________________(Printed Name)
NJROTC Unit:______________________________________________________________________High School
Date of your most recent pre-participation sports physical examination____________________________________
Part A – TO BE COMPLETED BY THE CADET AND PARENT/GUARDIAN
Directions: Please answer Yes or No to the following questions: (Do not leave any questions blank)
1. Do you have difficulty doing strenuous (great effort) exercise? ___________
2. Have you been told NOT to participate in long distance runs, such as a 1.0-mile-run? ____________
3. Have you been told NOT to do curl-ups or push-ups by a physician or other medical professional? __________
4. Do you exercise less than three times per week for at least thirty minutes? _____________
5. Have you had any broken bones or a serious accident in the last three months? _______________
6. Do you use tobacco of any kind? _______________
7. Have you experienced chest, neck, jaw or arm discomfort while doing physical activity? __________________
8. Do you have asthma or are you using an inhaler to aid in breathing?________________
9. Do you experience any shortness of breath with relatively low levels of exercise or exertion?_______________
10. In the last month have you felt any chest pain at rest? ________________
11. Do you have any known cardiac (heart) disease? _________________
12. Do you think you are overweight? _________________
13. Do you have dizzy/fainting spells, frequent headaches, or frequent back pains? ________________
14. Have you ever experienced dehydration after strenuous physical exercise? ____________________
15. Are you currently under treatment by a physician or other medical practitioner? ____________________
16. Has your mother or sister died without any explanation or suffered a heart attack before the age of 55? _______
17. Has your father or brother died without any explanation or suffered a heart attack before the age of 45? ______
18. Do you have high blood pressure or are you on blood pressure medication? ____________
19. Has a doctor ever told you that you have high cholesterol or are you on cholesterol medication? __________
20. Do you have sugar diabetes? ______________
21. Have you experienced episodes of rapid beating or fluttering of the heart? ________________
22. Do you suffer from lower leg swelling of both legs? _____________________
23. Do you have difficulty breathing or have sudden breathing problems at night? __________________
24. Do you have any personal history of metabolic disease (thyroid, renal, liver)? __________________
25. Do you have a bone, joint, or muscle problem that prevents you from doing strenuous exercises? _______
26. Have you unintentionally lost/gained more than 10 percent of your body weight since your last PFT? _______
27. Have you ever been diagnosed with Sickle Cell Trait?___________
___________________________________________
______________________________________________
Cadet Signature
Date
Parent/Guardian Signature
Date
Part B - If any of the answers to the questions above were YES, request that the following section be completed
and signed by a licensed medical doctor or registered school nurse:
Significant clinical history and/or current medication and treatment regimen of the above cadet: (Use reverse side
if necessary)
Recommended/released for participation in strenuous physical activities including the 1.0-mile-run? YES
NO
__________________________________________________________________________
Signature of Medical Practitioner
Date
CNET Form 1533/106 (09-02)
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