ÿþm

U.S. NAVAL SEA CADET CORPS
U.S. NAVY LEAGUE CADET CORPS
REPORT OF MEDICAL HISTORY
AUTHORIZATION, CONSENT AND RELEASE
Upon enrollment, the information requested below is required to provide the medical examiner an accurate history of illnesses and injuries that may
affect the applicant's ability to perform the strenuous physical exercise and exposure to living and working environments that are a part of the
NSCC/NLCC training program. Also this information will be provided to medical examiners in case of injury or il ness while participating in
NSCC/NLCC activities. If taking medications at time of enrollment, list in Block 9.
THE INFORMATION YOU PROVIDE MUST BE ACCURATE AND COMPLETE. You are encouraged to consult your private medical provider
regarding past illnesses. Proof of immunization for polio, measles, mumps, rubel a hepatitis B, pertussis and tetanus plus diphtheria and Menactra
vaccine for Meningitis must be attached.
After enrol ment, use this form to screen cadets for continued medical fitness before sending to Orientation, Recruit, Advanced and/or other trainings.
Commanding Officer’s (CO) and Commanding Officers of Training Contingents (COTC) retain the obligation to deny acceptance for enrol ment ortraining to any cadet if upon review of this form, it is determined that the cadet is not physical y/medical y qualified for participation unless MedicalCondition and/or disability accommodation per ADA guidelines has been requested and approved.
1. UNIT INFORMATION
1a. Unit Name
1b. Region
2. PERSONAL INFORMATION
2a. Last Name
2b. First Name
2d. Social Security Number
2f. Date of Birth (DD MMM YY)
2h. Parent/Guardian Name (cadets only)
2i. Home Address
2k. State
2l. Zip Code + 4
2m. Home Phone
2n. Date of Physical Examination (DD MMM YY)
3. MEDICAL PROVIDER/INSURANCE INFORMATION
3a. Medical Insurance Provider Name
3b. Medical Insurance Policy Number
3c. Medical Insurance Provider Address
3d. Medical Insurance Provider Phone
3e. Medical Provider Name
3f. Medical Provider Phone Number
4. MEDICAL HISTORY (Mark each item “YES” or “NO” Every item marked YES must be ful y explained in block 9: explain treatment to return cadet to medically fit for NSCC)
HAVE YOU EVER HAD OR DO YOU NOW HAVE
ANY OF THE FOLLOWING CONDITIONS:
4a. Tuberculosis or live with someone with tuberculosis
 4n. Head injury or concussion
4b. Chronic or recurrent abdominal or stomach pain
 4o. Seizures, convulsions, epilepsy, or fits
4c. Asthma or breathing problems related to exercise, pol en, etc.
 4p. Car, train, sea, and/or air sickness
4d. Been prescribed or use an inhaler
 4q. A period of unconsciousness
4e. Loss of vision in either eye
 4r. Heart trouble or murmur
4f. Loss of hearing or wear a hearing aid
 4s. Received counseling for emotional or behavior disorder
4g. Impaired use of arms, legs, hands, feet
 4t. Eating disorder (bulimia, anorexia)
4h. Knee problems
 4u. Sleepwalking
4i. Broken bones(s) (cracked or fractured)
 4v. Bedwetting
4j. Diabetes
 4w. Been hospitalized (if yes, why, when, where)
4k. Anemia (including sickle cell)
 4x. Any il ness or injury not mentioned above (if yes, explain)
4l. Dizziness or fainting spel s (including after exercise)
 4y. Advised to avoid certain physical activities (if yes, explain)
4m. Frequent or severe headaches
 4z. FEMALES ONLY: At what age did you begin menstrual cycle:
NSCADM 020 (REV 05/09)
REPORT OF MEDICAL HISTORY
5. IMMUNIZATION RECORDS (attach copy of immunization record to this form)
5a. Date of last tetanus or booster
5b. Date of Menactra Vaccine for Meningitis
5c. Date of negative PPD or Medical Provider Clearance for TB
6. ALLERGIES (Mark each item “YES” or “NO” Every item marked yes must be ful y explained in block 9.)
DO YOU NOW HAVE ANY OF THE FOLLOWING ALLERGIES:
6a. Bee or Wasp Sting
 6e. Latex
6b. Hay Fever or seasonal allergies
 6f. Any drug, E-mycin antibiotic, or sulfa al ergies, list in Block 9
6c. Insect Bites
 6g. Other Al ergies, list in Block 9
6d. Iodine/seafood
 6h. Food allergies, list in Block 9
6i. Describe the al ergic reaction and what condition occurs: (Include comment if mild or seasonal, or life threatening requiring immediate medical attention)
7. OVER THE COUNTER MEDICATIONS (for NLCC orientation, NSCC recruit, and Advanced Training. NOT Unit Dril s.
7a. Over the Counter (OTC) medications that may be administered at training evolutions by our staff when requested, for these conditions:
Cough Medicine (Robitussin DM, Dimetapp, etc.), Throat/Cough Drops (Chloraseptic, Halls, etc.), Decongestant (Sudafed, etc.) Milk of Magnesia, Dulcolax, Ex-Lax, or Glycerin Suppository Bacitracin ointment, Betadine, Neosporin ointment Pepto Bismol, Kaopectate, Immodium AD , etc.
Tylenol or Ibuprofen (Motrin, Advil, Aleve) Acetaminophen (Tylenol) or Ibuprofen (Motrin, Advil, Aleve) Calamine Lotion, Topical Lidocaine Spray or Aloe Vera Gel Bacitracin ointments, Betadine, Neosporin Ointment Other medications not listed above may be administered if so recommended by qualified medical staff.
Parents will be contacted directly when over the counter medications need to be administered during unit drills
8. STATEMENT OF UNDERSTANDING AND CONSENT
BY INITIALING YOU CERTIFY YOUR UNDERSTANDING & CONSENT TO THE FOLLOWING PARAGRAPHS: 8a. I understand that all medications wil be administered to the cadet based on dosing instructions on the medication bottle/package. In no instance
will cadets be allowed to self-medicate with any over the counter medication.
8b. I understand and consent that these written instructions may be superseded if, in the opinion of a medical provider, not doing so would place the
cadet in a medical y compromised condition.
8c. If you do not want your child to be administered over the counter medications, or certain medications concurrent with other medications, use Block
9 to specify those medications or write, “Do not medicate my child with any over the counter medications”.
9. REMARKS (please include comments as required by Blocks 4, 6, and/or 8. Also provide any other medical history that you or your physician deems important)
10. AUTHORIZATON AND RELEASE
I certify that to the best of my knowledge that the information provided is true and accurate and that I have disclosed al pertinent medical history.
Furthermore, I authorize the Naval Sea Cadet Corps, its agents, officials, and training staff members, to dispense medication listed on this
Authorization. I “Hold Harmless” the Naval Sea Cadet Corps from any and all liability, actions, or causes of action for damages or injury that may
arise, directly or indirectly, from my son/daughter’s use of medication while participating in Naval Sea Cadet Corps Activities. I understand that
training staff members may not be medical professionals and that medication wil be dispensed according to the manufacturer’s instructions and/or
the instructions I provided on this authorization.
10a. Parent/Guardian (for cadets) or Member Name (Type of Print)
10b. Signature
10c. Date (DD MMM YY)
NSCADM 020 (REV 05/09), Reverse

Source: http://www.seacadetscolumbus.org/join_nscc/Medical_History.pdf