Medical History Supplemental

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CADET APPLICATION
FOR OFFICIAL USE ONLY
U.S. NAVAL SEA CADET CORPS
U.S. NAVY LEAGUE CADET CORPS
MEDICAL HISTORY SUPPLEMENTAL
NOTICE
This form, used as a supplement to the Report of Medical History, is MANDATORY for all Cadets who are currently taking medication and will report to training with
prescription and/or non-prescription (over the counter) medications. Cadets may bring prescription and non-prescription medication to training as long as the medication is
not for a contagious illness or physical condition that would normally preclude his/her full participation in rigorous physical activity. Medication must NOT have expired. This
form is to be used in conjunction with the current report of Medical History when screening cadets prior to attending “ALL” trainings for those taking medications.
THE INFORMATION YOU PROVIDE MUST BE ACCURATE AND COMPLETE. If the cadet is taking prescription medications, a qualified medical provider must endorse
this document in Section 10, confirming the accuracy of the prescription information provided. Medical provider signature for OTC medications is NOT REQUIRED; parent
signature is sufficient for OTC medications.
Commanding Officers of Training Contingents (COTC) and Senior Escort Officers (SEO) retain the obligation and right to deny acceptance for training to any Cadet if upon
review of the Report of Medical History and this document, it is determined that the Cadet is not physically and/or medically qualified (without ADA accommodation). This
includes a determination that they do not have sufficient or qualified personnel to administer required medications. Parents/Legal Guardians should be consulted before
making these type determinations.
1. PERSONNEL INFORMATION
1a. Last Name
1b. First Name
1c. MI
1d. Social Security Number
2. TRAINING INFORMATION
2a. Training Code
2b. Training Start Date
2c. Training End Date
2d. Training Days
2d. Training Location
3. PACKAGING AND LABELING REQUIREMENTS
3a. Prescription Medication
3b. Non-Prescription Medication (Over the Counter)
Must be in the original container from the pharmacy or manufacturer.
Must be in the original container from the manufacturer.
Must have a complete prescription label attached to the container.
Must have a complete manufacturer’s label attached to the container
identifying the contents and directions for use.
The container will only contain the medication it is labeled for.
The Cadet must be the person prescribed the medication and his or her
The container will only contain the medication it is labeled for.
name must appear on the prescription label.
4. PRESCRIPTION OR NON-PRESCRIPTION MEDICATION (Use additional documents if more than three medications are provided)
4a. Name of Medication
4b. Strength
4c. Total Quantity Required
4d. Total Quantity Sent
4e. Storage (Use Block 7, if necessary)
4f. Frequency and Dosage (check one)
As needed, as labeled
On schedule, as labeled
Other: See Block 4l and/or Block 7
Refrigerate
Child-Proof Cap
Other:
4g. Prescribing Provider Name
4h. Prescribing Provider Phone Number
4i. Prescribing Provider Phone Number (alternate)
4j. Reason for medication (Describe in detail if necessary)
4k. Relevant side effects to be observed if any: (Such as reactions to food, dehydration, sun sensitivity, hives, other medication restrictions, decreased balance/motor
skills, hyperactivity, concentration, drowsiness, lethargy, etc.)
4l. List any other important information about this medication since access to medical information or facilities could be delayed due to training activities or location.
4m. Expected effects if medication is not taken as directed.
5. PRESCRIPTION OR NON-PRESCRIPTION MEDICATIONS (Use additional documents if more than three medications are provided)
5a. Name of Medication
5b. Strength
5c. Total Quantity Required
5d. Total Quantity Sent
5e. Storage (Use Block 7, if necessary)
5f. Frequency and Dosage (check one)
As needed, as labeled
On schedule, as labeled
Other: See Block 5l and/or Block 7
Refrigerate
Child-Proof Cap
Other:
5g. Prescribing Provider Name
5h. Prescribing Provider Phone Number
5i. Prescribing Provider Phone Number (alternate)
5j. Reason for medication (Describe in detail if necessary)
5k. Relevant side effects to be observed if any: (Such as reactions to food, dehydration, sun sensitivity, hives, other medication restrictions, decreased balance/motor
skills, hyperactivity, concentration, drowsiness, lethargy, etc.)
5l. List any other important information about this medication since access to medical information or facilities could be delayed due to training activates or location.
5m. Expected effects if medication is not taken as directed.
PREVIOUS EDITIONS ARE OBSOLETE
Formerly NSCTNG 025
NSCADM 001 (Rev 08/14), Page 7

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