CURRENTLY HAVE OR ANY HISTORY OF: YES NO
NOSE, SINUSES, MOUTH, AND LARYNX
LUNGS, CHEST WALL, PLEURA, AND MEDIASTINUM
ABDOMINAL ORGANS AND GASTROINTESTINAL SYSTEM
56. Missing a testicle, testicular implant, or undescended testicle Please check... Please check... 57. Variocele, hydrocele, or any scrotal mass, swelling or pain Please check... Please check... 58. Prostate problems Please check... Please check... 59. Sexually transmitted disease (syphilis, gonorrhea, chlamydia, genital warts, herpes, etc.) Please check... Please check...
SPINE AND SACROILIAC JOINTS
74. Foot trouble (e.g., pain, corns, bunions, warts, ingrown toenails, etc.) Please check... Please check... 75. Knee trouble (e.g., locking, giving out, or ligament injury, etc.) Please check... Please check... 76. Painful hip, knee, ankle, foot or toes Please check... Please check... 77. Dislocated hip, knee, ankle, foot or toes Please check... Please check...
MISCELLANEOUS CONDITIONS OF THE EXTREMITIES
78. Bone, joint, or other orthopedic deformity Please check... Please check... 79. Loss of finger or toe, or extra finger or toe Please check... Please check... 80. Loss of the ability to fully flex (bend) or fully extend a finger, toe, or other joint Please check... Please check... 81. Impaired use of arms, hands, legs, or feet (any reason) Please check... Please check... 82. Arthritis, rheumatism, gout, or bursitis Please check... Please check... 83. Any swollen joint(s) Please check... Please check... 84. Surgery on any joint/bone (including arthroscopy) Please check... Please check... 85. Plate(s), screw(s), rod(s) or pin(s) in any bone Please check... Please check... 86. Pain or swelling at the site of an old fracture Please check... Please check... 87. Any need to use corrective devices such as prosthetic devices, knee brace(s), back support(s), lifts or orthotics Please check... Please check... 88. Any other orthopedic, muscle, or sports injury problems Please check... Please check...
СURRENTLY HAVE OR ANY HISTORY OF: YES NO
BLOOD AND BLOOD FORMING TISSUES
103. Adverse reaction to medication (describe reaction in Section IV) Please check... Please check... 104. Adverse reaction to serum, insect bites, or stings Please check... Please check... 105. Allergy to foods (milk, eggs, fish, meat, nuts, etc.) Please check... Please check... 106. Allergy to wool, latex, or other material Please check... Please check... 107. Tuberculosis or lived with someone who had tuberculosis Please check... Please check... 108. Positive test for tuberculosis (PPD or blood test) Please check... Please check... 109. Malaria Please check... Please check... 110. Disorder(s) of your immune system (including HIV) Please check... Please check... 111. Car, train, sea, or air sickness Please check... Please check...
LEARNING, PSYCHIATRIC, AND BEHAVIORAL
131. Evaluated or treated for Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD) Please check... Please check... 132. Taken (or taking) medication, drugs, or any substance to improve attention, behavior, or physical performance Please check... Please check... 133. Diagnosed with a learning disorder, to include dyslexia Please check... Please check... 134. Received counseling of any type Please check... Please check... 135. Seen a psychiatrist, psychologist, social worker, counselor or other professional for any reason (inpatient or out-patient) including counseling or treatment for school, adjustment, family, marriage, divorce, depression, anxiety, or treatment of alcohol, drug or substance abuse (Applicant or recruiter will request sealed medical supporting documents from health care providers marked "CONFIDENTIAL: MEPS MEDICAL DEPARTMENT" and submit directly to MEPS medical personnel.) Please check... Please check... 136. Been expelled or suspended from school Please check... Please check... 137. Been kicked out or removed from your home Please check... Please check... 138. Been arrested or other encounters with law enforcement Please check... Please check... 139. Been evaluated or treated, either with medication or counseling, for a mental condition, depression or excessive worry Please check... Please check... 140. Nervous trouble of any sort (anxiety or panic attacks) Please check... Please check... 141. Anorexia, bulimia, or other eating disorder Please check... Please check... 142. Habitual stammering or stuttering Please check... Please check... 143. Have you ever purposely cut or harmed yourself Please check... Please check... 144. Have you ever attempted or considered suicide Please check... Please check... 145. Used illegal drugs or abused prescription drugs Please check... Please check... 146. Have you been evaluated, treated, or hospitalized for substance abuse, addiction or dependence (including illegal drugs, prescription medications or other substances) Please check... Please check... 147. Have you been evaluated, treated, or hospitalized for alcohol abuse, dependence, or addiction Please check... Please check... 148. Post-traumatic Stress Disorder or excessive stress requiring counseling and/or medication following a traumatic experience Please check... Please check... 149. Any other learning, psychiatric, or behavioral problems Please check... Please check...
153. Are you taking any medications, to include over the counter medications (OTCs), vitamin, herbal, or nutritional supplements (If "yes", list all in Section IV.) Please check... Please check... 154. Any recent unexplained gain or loss of weight Please check... Please check... 155. Artificial or replacement body part (eye, bone, palate, hip, knee, joint, leg, arm, etc.) Please check... Please check... 156. Have you ever had any illness or injury other than those already noted? (If "yes", specify when, where and give details in Section IV.) Please check... Please check... 157. Have you ever been treated in an Emergency Room? (If "yes", explain in Section IV.) Please check... Please check... 158. Have you ever been a patient in any type of hospital (including being kept overnight)? (If "yes", specify when, where, why, and name of doctor and complete address of hospital in Section IV.) Please check... Please check... 159. Have you ever had, or have you been advised to have any operations or surgery? (If "yes", describe and give age at which occurred in Section IV.) Please check... Please check... 160. Have you ever been rejected for military Service for any reason? (If "yes", give date and reason in Section IV.) Please check... Please check... 161. Have you ever been discharged from the military Service for any reason? (If "yes", give date, reason, and type of discharge, whether honorable, other than honorable, for unfitness or unsuitability in Section IV.) Please check... Please check... 162. Have you ever been refused employment or been unable to hold a job or stay in school because of any of the following: (If "yes", answer a - d below and give reasons in Section IV.) Please check... Please check... a. Sensitivity to chemicals, dust, sunlight, etc. Please check... Please check... b. Inability to perform certain motions Please check... Please check... c. Inability to stand, sit, kneel, lie down, etc. Please check... Please check... d. Other medical reasons Please check... Please check... 163. Applied for and/or received disability evaluation and/or compensation for an injury or other medical conditions (If "yes", provide details in Section IV.) Please check... Please check... 164. Have you ever been denied life insurance? (If "yes", provide reason(s) in Section IV.) Please check... Please check...