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					USCGC HEALY (WAGB 20)
Scientific Mission Personnel Data Sheet – Medical History
Date Last Modified: 28 FEB 02                                                                    Page 1 of 6



                      USCGC HEALY (WAGB 20)
                      Scientific Mission Personnel Data Sheet
                      Medical History

Mission Number:       ___________              (Please Print Legibly)

Date:                 ___________

Name:                __________________________         Date of Birth:           ___________________________

Address:             __________________________         Place of Birth:          ___________________________
                     __________________________
                                                        Race/Nationality:        ___________________________
Telephone No:        __________________________
                                                        Native Language:         ___________________________
Social Security
Number:              __________________________
                                                        Educational
                                                        Level:                   ___________________________
Next of Kin:         __________________________
                                                        Years of Maritime
                                                        Service:                 ___________________________
Address:             __________________________
                     __________________________         Maritime Rating:         ___________________________

Telephone No:        __________________________         Marital Status:          ___________________________

Family Doctor:       __________________________         Citizenship:               Native
                                                                                   Naturalized
Address:             __________________________                                    Alien
                     __________________________
                                                        Date of last physical:                     ____________
Telephone No:        __________________________
                                                        Date of last hospitalization:              ____________
                                                        Number of days:                            ____________



History of Family Illness                               Statement of Present Health
Check if there is any history in your family of:
                                                        What is your                Excellent
                                                        present health?             Good
   Diabetes                Obesity                                                  Fair/Poor (Please Explain):
   High Blood Pressure     Gout                                                  ___________________________
   Stroke                  Asthma                                                ___________________________
   Heart Trouble           Psychiatric Illness
   Tuberculosis            Allergy                      Height (inches):                           ____________
   Alcoholism              High Blood Fats              Usual weight (lbs):                        ____________
   Jaundice                Easy Bleeding                Usual blood pressure:                      ____________
   Cancer of:    ___________________________            Hair color:                                ____________
   Other: _________________________________             Eye Color:                                 ____________
USCGC HEALY (WAGB 20)
Scientific Mission Personnel Data Sheet – Medical History
Date Last Modified: 28 FEB 02                                                                 Page 2 of 6
Statement of Present Health (continued)
Do you take non-                                         Do you take
prescription drugs                                       prescription drugs
routinely?               No                              routinely?               No
                         Yes (Please Specify)                                     Yes (Please Specify)
                      __________________________                               ___________________________
                      __________________________                               ___________________________
                      __________________________                               ___________________________

Do you use                                               Are you under the
recreational drugs?                                      care of a physician
                         No                              now?                     No
                         Yes (Please Specify)                                     Yes (Please Specify)
                      __________________________                               ___________________________
                      __________________________                               ___________________________
                      __________________________                               ___________________________

What is your vision (with glasses)?      _____/______
                  (without glasses)?



Past Medical History (for additional space, use back of page)
Have you ever been refused employment or been unable to hold a job or stay in                               Don’t
school because of:                                                                      Yes       No        Know

Sensitivity to chemicals, dust, sunlight, etc.

Inability to perform certain motions:

Inability to assume certain positions:

Other medical reasons (If yes, give reasons)

Have you ever been treated for a nervous condition? (If yes, specify when, where
and give details)

Have you ever been denied life insurance? (If yes, state reason and give details)

Have you had, or have you been advised to have any operations? (If yes, describe
and give age at which occurred)

Have you ever been a patient in any type of hospitals? (If yes, specify when, where,
why, name of doctor and complete address of hospital)

Have you consulted or been treated by clinics, physicians, healers, or other
practitioners, within the past 5 years for other than minor illnesses? (If yes, give
complete address of doctor, hospital and details)

Have you ever been rejected from military service because of physical, mental or
other reasons? (If yes, give date and reasons for rejection)
USCGC HEALY (WAGB 20)
Scientific Mission Personnel Data Sheet – Medical History
Date Last Modified: 28 FEB 02                                                                Page 3 of 6

Past Medical History (Continued):                                                                          Don’t
                                                                                       Yes       No        Know
Have you ever been discharged from military service because of physical, mental or
other reasons? (If yes, give date, reasons and type of discharge: honorable, other
than honorable, unfit or unsuitable)

Have you ever received, is there pending, or have you applied for pension or
compensation for existing disability? (If yes, specify what kind, granted by whom,
what amount, when and why)

Have you ever?

Lived with anyone who had tuberculosis?

Coughed up blood?

Bled excessively after injury or tooth extraction?

Attempted suicide?

Been a sleepwalker?

Do You?

Wear glasses or contact lenses?

Have vision in both eyes?

Wear a hearing aid?

Stutter or stammer habitually?

Wear a brace, back support or truss?


Have you ever had, or have you now?
                                               Don’t                                                       Don’t
                                 Yes    No     Know                                    Yes       No        Know

Scarlet Fever                                           Emphysema

Rheumatic Fever                                         Limit of joint motion

Swollen or painful joints                               Cramps in your legs

Frequent or severe                                      Frequent indigestion /
headaches                                               stomach ulcer

Dizziness / fainting spells                             Stomach, liver or intestinal
                                                        trouble

Eye Trouble                                             Gall bladder trouble or gall
                                                        stones
USCGC HEALY (WAGB 20)
Scientific Mission Personnel Data Sheet – Medical History
Date Last Modified: 28 FEB 02                                                           Page 4 of 6

Past Medical History (continued)

Have you ever had, or have you now?
                                               Don’t                                                  Don’t
                                Yes     No     Know                                   Yes   No        Know
Ear, nose or throat trouble                            Jaundice or hepatitis

Hearing loss                                           Adverse reaction to serum,
                                                       drug, medicine or foods.

Chronic or frequent colds                              Broken bones

Severe tooth / gum trouble                             Tumor, growth, cyst, cancer

Sinusitis                                              Rupture / hernia

Hay fever                                              Piles or rectal disease

Head injury                                            Frequent / painful urination

Skin diseases                                          Bedwetting since Age 12

Thyroid trouble                                        Kidney stones or blood in
                                                       urine

Tuberculosis                                           Sugar or albumin in urine

                                                       STD (Sexually Transmitted
                                                       Disease) – syphilis,
Asthma                                                 gonorrhea

Shortness of breath                                    Recent weight gain or loss

Pain or pressure in chest                              Arthritis, rheumatism, or
                                                       bursitis

Chronic cough                                          Bone, joint or other
                                                       deformity

Palpitation / pounding                                 Lameness
heart

Heart trouble                                          Loss of finger or toe

High or low blood pressure                             Kidney / bladder trouble

Bronchitis                                             Herpes

“Trick” or locked knee                                 Anemia / blood disorder

Foot trouble                                           Glaucoma

Neuritis                                               Abnormal chest x-ray
USCGC HEALY (WAGB 20)
Scientific Mission Personnel Data Sheet – Medical History
Date Last Modified: 28 FEB 02                                                                    Page 5 of 6

Past Medical History (continued)

Have you ever had, or have you now?
                                               Don’t                                                           Don’t
                                 Yes    No     Know                                        Yes       No        Know
Paralysis (include infantile)                          Abnormal G.I. x-ray

Epilepsy or fits                                       Abnormal EKG

Car, train, sea or air
sickness                                               Use tobacco

Frequent trouble sleeping                              Use alcohol

Depression or excessive                                Painful or “trick” shoulder
worry                                                  or elbow

Loss of memory or amnesia                              Recurrent back pain

Nervous trouble of any sort                            Females only, have you ever:

                                                       Been treated for a female
Periods of unconsciousness                             disorder

                                                       Had a change in menstrual
Gout                                                   pattern

Hardening of arteries




Immunizations
Have you had any of the following immunizations? Date / Mon / Year (example: 28 FEB 02)

                                Don’t                                                        Don’t
                   Yes    No    Know      Date                               Yes      No     Know           Date
Tetanus                                 ________       Typhoid                                            ________

Smallpox                                ________       Typhus                                             ________

Yellow fever                            ________       Gamma globulin                                     ________

Plague                                  ________       Diphtheria                                         ________

BCG (TB)                                ________       Malaria                                            ________

Cholera                                 ________       Other                                              ________
USCGC HEALY (WAGB 20)
Scientific Mission Personnel Data Sheet – Medical History
Date Last Modified: 28 FEB 02                                                                     Page 6 of 6


Medical Release
I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best
of my knowledge. I hereby authorize facilities holding my medical records to release a transcript to the United
States Coast Guard for the purpose of acquiring medical advice for my treatment for medical problems which
could occur aboard the WAGB-20. I also authorize USCG to maintain, periodically update, and release this
information to shoreside medical facilities for continuation of medical care.

                                                           ___________________________________
                                                           Signature (Scientific Party Member) / Date


This record is being provided by:         ________________________________________________
                                                     Name of Subscribing Company


Additional Information

				
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