Navy Option/marine Option Nrotc Program Application Form (Page 6 of 17) in pdf

Navy Option/marine Option Nrotc Program Application Form Page 6

REPORT OF MEDICAL HISTORY

(This information is for NROTC use only and will not be released to unauthorized persons)

Last Name

First Name

Middle Name

Home Address

Parent Guardian Name/Address

The information requested below is required to provide a medical examiner an accurate history of illnesses or

injuries that may affect the applicant’s ability to perform the strenuous physical exercise that is part of the

environment of the NROTC training and testing program.

The information provided must be accurate and complete. You are encouraged to consult with your private

physician (if he is not the examiner) and parents to obtain information regarding past illnesses and injuries. Proof of

immunization for Polio, Measles, Mumps, Rubella and Diphtheria, Tetanus and Pertussis (DPT) plus Diphtheria and

Tetanus (dt) booster should be provided to the medical examiner if available from personal medical records.

MEDICAL HISTORY

(Indicate “YES” or “NO” with any remarks in the “Comments” box. Attach copies of any records you may have

regarding these or other conditions you think the medical examiner should know about.)

YES

QUESTIONS

COMMENTS

1. Are you taking or do you require any medications? List them.

2. Have you been hospitalized? If so, when and what for.

3. Have you had a head injury or concussion, or passed out after

exercise?

4. Have you had loss of consciousness?

5. Have you been treated for an emotional or behavioral disorder?

6. Have you sprained, strained, dislocated, broken, or had a severe pain in

your head, arms, back, legs or neck?

7. Have you been diagnosed as having, or do you think you might have,

any of the following conditions:

Allergies to:

(1)

Insect stings/bites

(2)

Foods (list)

(3)

Medicine (name)

(4)

Other (specify)

Anemia (including sickle cell)

NROTCUAU FORM 6120/2 (Rev. 7/02) FRONT

Navy Option/marine Option Nrotc Program Application Form Page 6