| Head Injury | No |
|---|---|
| Neck/Back Injury | No |
| Absence of one eye | No |
| Absence of Kidney | No |
| Loss of Consciousness | No |
| Shoulder/Elbow Injury | No |
| Fainting Spells | No |
| Knee/Ankle Injury | No |
| Kidney Disease | No |
| Convulsions | No |
| Hernia | No |
| Heart Disease or Murmur | No |
| Epilepsy | No |
| Asthma | No |
| Menstrual Disorder | No |
| Paralysis | No |
| Diabetes | No |
| Hearing Loss | No |
| Fractured Bones | No |
| Pregnancy | No |
| Perforated Ear Drum | No |
| Wears Glasses | No |
| Wears Contact Lenses | No |
| 2. I acknowledge that vaccinations for Tetanus/Diphtheria, Measles, and Polio are current. | Acknowledge |
| 3. List any health factor that requires a limited program of physical activity on the part of your son or daughter. If none, so state. | None |
| 4. Is your son or daughter taking a prescribed medicine which must be continued while he/she is at Camp Pendleton? | No |
| 5. Has the applicant ever had significant allergies? Select all that apply. | None |
| 6. Family Physician Name | Dr. Kwabena |
| 7. List the candidate's health insurance provider: | IEHP |
| Policy Number | 20111100096000 |
| 04 Parent/Guardian Signature |  |
