Medical Forms Page 9
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11Yes
No
Please indicate whether or not the following apply to you
Comments
18
Wear glasses or contact lenses
19
Bleeding disorders
20
Alcoholism
21
Any problems related to diving
22
Nervous tension or emotional problems
23
Take tranquilizers
24
Perforated ear drums
25
Hay fever
26
Frequent sinus trouble, frequent drainage from the nose, post-nasal
drip, or stuffy nose
27
Frequent earaches
28
Drainage from the ears
29
Difficulty with your ears in airplanes or on mountains
30
Ear surgery
31
Ringing in your ears
32
Frequent dizzy spells
33
Hearing problems
34
Trouble equalizing pressure in your ears
35
Asthma
36
Wheezing attacks
37
Cough (chronic or recurrent)
38
Frequently raise sputum
39
Pleurisy
40
Collapsed lung (pneumothorax)
41
Lung cysts
42
Pneumonia
43
Tuberculosis
Revised 12/09
Page 62
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