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U.S. NAVAL SEA CADET CORPS
REPORT OF MEDICAL HISTORY
U.S. NAVY LEAGUE CADET CORPS
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 illness 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, rubella hepatitis B, pertussis and tetanus plus diphtheria and Menactra
vaccine for Meningitis must be attached.
After enrollment, 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 enrollment or training to any cadet if upon review of this form, it is determined that the cadet is not physically/medically qualified for participation unless Medical Condition and/or disability accommodation per ADA guidelines has been requested and approved.
Social Security Number
Date of Birth (DD MMM YY)
Parent/Guardian Name (cadets only)
Zip Code + 4
Date of Physical Examination (DD MMM YY)
MEDICAL PROVIDER/INSURANCE INFORMATION
Medical Insurance Provider Name
Medical Insurance Policy Number
Medical Insurance Provider Address
Medical Insurance Provider Phone
Medical Provider Name
Medical Provider Phone Number
MEDICAL HISTORY (Mark each item “YES” or “NO” Every item marked YES must be fully 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:
Tuberculosis or live with someone with tuberculosis
Head injury or concussion
Chronic or recurrent abdominal or stomach pain
Seizures, convulsions, epilepsy, or fits
Asthma or breathing problems related to exercise, pollen, etc.
Car, train, sea, and/or air sickness
Been prescribed or use an inhaler
A period of unconsciousness
Loss of vision in either eye
Heart trouble or murmur
Loss of hearing or wear a hearing aid
Received counseling for emotional or behavior disorder
Impaired use of arms, legs, hands, feet
Eating disorder (bulimia, anorexia)
Broken bones(s) (cracked or fractured)
Been hospitalized (if yes, why, when, where)
Anemia (including sickle cell)
Any illness or injury not mentioned above (if yes, explain)
Dizziness or fainting spells (including after exercise)
Advised to avoid certain physical activities (if yes, explain)
Frequent or severe headaches
4z. FEMALES ONLY:
At what age did you begin menstrual cycle:
NSCADM 020 (REV 05/09)
REPORT OF MEDICAL HISTORY
IMMUNIZATION RECORDS (attach copy of immunization record to this form)
Date of last tetanus or booster
Date of Menactra Vaccine for Meningitis
Date of negative PPD or Medical Provider Clearance for TB
ALLERGIES (Mark each item “YES” or “NO” Every item marked yes must be fully explained in block 9.)
DO YOU NOW HAVE ANY OF THE FOLLOWING ALLERGIES:
Bee or Wasp Sting
Hay Fever or seasonal allergies
Any drug, E-mycin antibiotic, or sulfa allergies, list in Block 9
Other Allergies, list in Block 9
Food allergies, list in Block 9
Describe the allergic reaction and what condition occurs: (Include comment if mild or seasonal, or life threatening requiring immediate medical attention)
OVER THE COUNTER MEDICATIONS (for NLCC orientation, NSCC recruit, and Advanced Training. NOT Unit Drills.
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
STATEMENT OF UNDERSTANDING AND CONSENT
BY INITIALING YOU CERTIFY YOUR UNDERSTANDING & CONSENT TO THE FOLLOWING PARAGRAPHS:
I understand that all medications will 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.
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 medically compromised condition.
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
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)
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 all 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 will be dispensed according to the manufacturer’s instructions and/or the instructions I provided on this authorization.
Parent/Guardian (for cadets) or Member Name (Type of Print)
Date (DD MMM YY)
NSCADM 020 (REV 05/09), Reverse
Ingredients: Contains a special, high-quality grease with graphite, copper flake, aluminum powder and zinc oxide. NEVER SEEZ ® Shelf Life: Never-Seez® Regular Grade does not deteriorate with age when stored unopened at temperatures below 120°F (49°C). Anti-Seize & Lubricating Compound Quality and performance are guaranteed for five years from the date of manufacture on unopen
Pre-Travel Questionnaire It is essential that you visit your travel nurse well in advance of travelling abroad. They will be able to advice you personally regarding vaccinations, malaria prevention and general health issues you should consider for your destination. To help us have all the right information at hand please complete the details and return to reception or you can