in-processing / scheduled in-processing date / food / /
MedicalCondition
minor arthritis / backaches / allergies / Muscular aches / headaches / Mumps / Headache / Common Cold / FLU / years Measles / Current FLU / menstrual cramps / alcohol abuse / Nausea NAME / hallucinations / bloating / Tetanus / *varicella / Upper Respiratory Allergies / hay fever / Diarrhea / illness / Cramps / paranoia / Sore Throat / coughs / minor aches / disease / Backache / diarrhea NAME / Menstrual Cramps NAME / anxiety disorders / completed *Hepatitis B / nasal congestion / sickness / Back Ache / Itching / fever / bipolar disorders / Runny Nose / Toothache / Rubella / drug abuse / Muscular Aches NAME / pains / Cough / depression / upper respiratory allergies NAME / Varicella / injuries / /
MedicalTreatment
Immunization / vaccination / /
Organization
Reviewed By MYC Medical Department / Freestate ChalleNGe Academy / Selection Committee / MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE IMMUNIZATION CERTIFICATE FORM / Medical Department / Completed MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE IMMUNIZATION CERTIFICATE FORM / / /
Over The Counter Medication / Benadryl / Tylenol / COPY THIS FORM IF THE PHYSICIAN WRITES FOR MORE THAN ONE MEDICATION / OVER-THE-COUNTER MEDICATION / Maryland Law Only One Medication / Begin Medication / OTC Medication / Discontinue Medication / Naproxen / Diphen / Excedrin / Ibuprofen / Prescrption Medication / Generic Cold Capsules / Physician’s Authorization For PRESCRIPTION MEDICATION / Claritin / Midol / Lomotil / ONE FORM FOR EACH MEDICATION / /
Freestate ChalleNGe Academy Medical Forms * Bldg E 4230 Beal Road * Aberdeen Proving Ground * Maryland[removed]Office[removed]or[removed]APPLICATION CHECKLIST APPLICANT’S NAME: ______________________________DAT