| Document Date: 2013-06-04 16:26:19
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IndustryTerm food allergies / food / / MedicalCondition glaucoma / hernia / Frequent urination Menstrual cramps / food allergy / severe headaches Dizziness / ulcers Hepatitis / Other chronic medical illnesses Sleep disorder / food allergies / bedwetting problems ADD / liver problems Diarrhea / Cancer / chest pain / Mental illness / Kidney disease / fainting / Birth Height Weight Grade CAPID Charter Number Hair Color Eye Color Gender Allergies / Ear infections / emphysema / serious allergic reaction Asthma / Attention Deficit Disorder / seizure Stroke / Other Allergies / activity Heart Attack / Hearing loss / Chronic / injury Migraine / Depression / neck pain / constipation Hernia / unconsciousness Epilepsy / nasal stuffiness Anaphylaxis / leukemia Blood disease / apnea Serious Injury OPR/ROUTING / Diabetes / aid Allergies / Head injury / / MedicalTreatment vegetarian diets / heart catheterization / hysterectomy / surgery / surgeries / / Position walker / adult leader / /
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CAP MEMBER HEALTH HISTORY FORM This information is CONFIDENTIAL and for official use only. It cannot be released to unauthorized persons. Answer all questions as accurately as possible so that the activity or encampment