Title: Mission No:
Author: DEverette
Last saved by: Kim Cummings
Company: United States Coast Guard

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

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 present health? | ☐ Excellent |
| | ☐ 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: | ____________
Statement of Present Health (continued)
Do you take non-prescription drugs routinely? | ☐ No | | Do you take prescription drugs routinely? | ☐ No |
| ☐ Yes (Please Specify) | | ☐ Yes (Please Specify)
| __________________________ | | ___________________________
| __________________________ | | ___________________________
| __________________________ | | ___________________________
Do you use recreational drugs? | ☐ No | | Are you under the care of a physician 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 school because of: | Yes | No | Don’t 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) | ☐ | ☐ | ☐

Past Medical History (Continued): | Yes | No | Don’t 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?
| Yes | No | Don’t Know | | Yes | No | Don’t Know
Scarlet Fever | ☐ | ☐ | ☐ | Emphysema | ☐ | ☐ | ☐
Rheumatic Fever | ☐ | ☐ | ☐ | Limit of joint motion | ☐ | ☐ | ☐
Swollen or painful joints | ☐ | ☐ | ☐ | Cramps in your legs | ☐ | ☐ | ☐
Frequent or severe headaches | ☐ | ☐ | ☐ | Frequent indigestion / stomach ulcer | ☐ | ☐ | ☐
Dizziness / fainting spells | ☐ | ☐ | ☐ | Stomach, liver or intestinal trouble | ☐ | ☐ | ☐
Eye Trouble | ☐ | ☐ | ☐ | Gall bladder trouble or gall stones | ☐ | ☐ | ☐

Past Medical History (continued)
Have you ever had, or have you now?
| Yes | No | Don’t Know | | Yes | No | Don’t 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 | ☐ | ☐ | ☐
Asthma | ☐ | ☐ | ☐ | STD (Sexually Transmitted Disease) – syphilis, 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 heart | ☐ | ☐ | ☐ | Lameness | ☐ | ☐ | ☐
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 | ☐ | ☐ | ☐

Past Medical History (continued)
Have you ever had, or have you now?
| Yes | No | Don’t Know | | Yes | No | Don’t 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 worry | ☐ | ☐ | ☐ | Painful or “trick” shoulder or elbow | ☐ | ☐ | ☐
Loss of memory or amnesia | ☐ | ☐ | ☐ | Recurrent back pain | ☐ | ☐ | ☐
Nervous trouble of any sort | ☐ | ☐ | ☐ | Females only, have you ever:
Periods of unconsciousness | ☐ | ☐ | ☐ | Been treated for a female disorder | ☐ | ☐ | ☐
Gout | ☐ | ☐ | ☐ | Had a change in menstrual pattern | ☐ | ☐ | ☐
Hardening of arteries | ☐ | ☐ | ☐ |
Immunizations
Have you had any of the following immunizations? Date / Mon / Year (example: 28 FEB 02)
| Yes | No | Don’t Know | Date | | | Yes | No | Don’t Know | Date
Tetanus | ☐ | ☐ | ☐ | ________ | | Typhoid | ☐ | ☐ | ☐ | ________
Smallpox | ☐ | ☐ | ☐ | ________ | | Typhus | ☐ | ☐ | ☐ | ________
Yellow fever | ☐ | ☐ | ☐ | ________ | | Gamma globulin | ☐ | ☐ | ☐ | ________
Plague | ☐ | ☐ | ☐ | ________ | | Diphtheria | ☐ | ☐ | ☐ | ________
BCG (TB) | ☐ | ☐ | ☐ | ________ | | Malaria | ☐ | ☐ | ☐ | ________
Cholera | ☐ | ☐ | ☐ | ________ | | Other | ☐ | ☐ | ☐ | ________

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