Navy Option/marine Option Nrotc Program Application Form Page 7
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17c)
Asthma
d)
Diabetes
e)
Motion Sickness
f)
Seizure/Convulsion
g)
Sleep Walking
h)
Bed wetting/Enuresis
8. Is there any activity that you have been medically advised to avoid
such as running, swimming, lifting, or participation in strenuous physical
activity? If YES, explain.
9. Females: At what age did you begin your menstrual period?
Have you experienced any problems?
IMMUNIZATION RECORD
(Indicate date of last immunization)
Measles ______ Rubella ______ DPT:dt ______ Mumps ______ Polio ______ TB Test ______ Other ______/______
_______________________________________________________________________________________________
FAMILY HISTORY
Parents alive?
YES
NO
Are they well? __________________
Brothers/Sisters
YES
NO
Are they well? __________________
Addition Remarks (Family History)
NROTCUAU FORM 6120/2 (Rev. 7/02) BACK
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