Capf 160 Form PDF Details

Understanding the CAPF 160 Form is essential for members of the Civil Air Patrol (CAP), especially as it focuses on ensuring the health and safety of participants in CAP activities or encampments. Described as a Member Health History Form, it plays a crucial role in providing a detailed account of a member's medical history, allergies, medications, and any conditions that might affect their participation in CAP events. The form has been designed to be comprehensive, asking for information ranging from basic personal details to specific health concerns such as allergies, past surgeries, and any chronic medical illnesses. Additionally, it includes sections for dietary restrictions and current medications, ensuring that activity staff are well-informed and prepared to assist in case a participant is unable to communicate their health needs. The CAPF 160 Form also incorporates consent sections for minors, outlining permissions for medical treatment and medication administration, making it a pivotal document for safeguarding member health and facilitating informed healthcare decisions during CAP activities.

QuestionAnswer
Form NameCapf 160 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescap form 160, capf 160 161, capf 160, cap form 160 161

Form Preview Example

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 staff can make themselves aware of any pre-existing medical problems or conditions and be alert to help you. This form will also provide medical information in a case when you are unable to do so.

Name (Last, First, Middle)

Grade

CAPID

Charter Number

Date of Birth

Height

Weight

Hair Color

Eye Color

Gender

Allergies: List Names of Medication or Other Allergies (i.e., bee sting, food, plants) and types of reactions; please note food allergy details with dietary restrictions below on back as well.

Do You Now Have Or Have You Ever Had Any Of The Following? Explain any yes’ in the remarks section below or attach additional sheet. Conditions not specifically noted below having the potential to interfere with performance during the special activity or encampment should be documented in the remarks section.)

If “Yes” is marked in an item with multiple choices, please circle which problem applies.

 

No Yes

 

No Yes

 

 

 

 

Decreased vision, glaucoma, contacts

 

 

 

 

Chronic or recurring injuries

 

 

 

 

Ear infections, perforation

 

 

 

 

Activity, mobility restrictions

 

 

 

 

 

 

 

 

 

 

 

 

Difficulty equalizing ears

 

 

 

 

Use of cane, walker, wheelchair

 

 

 

 

 

 

 

 

 

 

 

 

Hearing loss, hearing aid

 

 

 

 

Back or neck pain or injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Allergies, nasal stuffiness

 

 

 

 

Migraine or severe headaches

 

 

 

 

 

 

 

 

 

 

 

 

Anaphylaxis, serious allergic reaction

 

 

 

 

Dizziness or fainting spells

 

 

 

 

 

 

 

 

 

 

 

 

Asthma, emphysema (COPD)

 

 

 

 

Head injury, unconsciousness

 

 

 

 

 

 

 

 

 

 

 

 

Ever use an inhaler

 

 

 

 

Epilepsy or seizure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Short of Breath with activity

 

 

 

 

Stroke, paralysis

 

 

 

 

 

 

 

 

 

 

 

 

Heart Attack, chest pain, angina

 

 

 

 

Thyroid problems (low or high)

 

 

 

 

 

 

 

 

 

 

 

 

Heart murmur, heart problems

 

 

 

 

Diabetes, high or low blood sugars

 

 

 

 

 

 

 

 

 

 

 

 

Congestive heart failure

 

 

 

 

Cancer, leukemia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Irregular or rapid heartbeat

 

 

 

 

Blood disease, hemophilia

 

 

 

 

 

 

 

 

 

 

 

 

High or low blood pressure

 

 

 

 

Motion sickness

 

 

 

 

 

 

 

 

 

 

 

 

Stomach trouble, ulcers

 

 

 

 

Special diet, food allergies

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis or liver problems

 

 

 

 

Current bedwetting problems

 

 

 

 

 

 

 

 

 

 

 

 

Diarrhea, constipation

 

 

 

 

ADD (Attention Deficit Disorder)

 

 

 

 

 

 

 

 

 

 

 

 

Hernia or rupture

 

 

 

 

Mental illness (bipolar, other)

 

 

 

 

 

 

 

 

 

 

 

 

Kidney disease or stones

 

 

 

 

Depression, anxiety, suicidal

 

 

 

 

 

 

 

 

 

 

 

 

Prostate problems (men)

 

 

 

 

Admission to the hospital

 

 

 

 

 

 

 

 

 

 

 

 

Frequent urination

 

 

 

 

Other chronic medical illnesses

 

 

 

 

 

 

 

 

 

 

 

 

Menstrual cramps (women)

 

 

 

 

Sleep disorder, sleep apnea

 

 

 

 

 

 

 

 

 

 

 

 

Broken bone, joint problems

 

 

 

 

Serious Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CAPF 160 JUN 13

OPR/ROUTING: HS

Dietary Restrictions or Limitations (List any dietary restrictions like food allergies, diabetes, gluten-free, vegetarian diets, etc.)

Past Surgical History (List all surgeries including tonsils, ear tubes, appendix, gall bladder, hernia, hysterectomy, heart, heart catheterization, bone and joint and all other surgeries.)

Date Tetanus

Booster

No Td or Tdap

Date:

 

Pneumonia

Hepatitis Vaccine

Vaccine

No

No

Date:

Date:

 

 

Varicella Immuni- zation/chickenpox

No

Date:

Influenza Vaccine No

Date:

Medication Information - Include supplements, over-the-counter medicines, herbals, creams, etc., or write “None”.

 

 

Times

 

Any Special Dosing or Storage

 

Tablet

taken

Reason for

Instructions (i.e., as needed, with

Name of Medication/Inhaler

Strength

per day

Medication

meals, must be refrigerated, etc.)

1.

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

Social History

Tobacco Use (packs per day, years smoked, smokeless tobacco use)

Occupation (student or other)

Religious Preference

Remarks (Attach additional sheet if needed)

CONSENT FOR MINOR CADET PARTICIPATION, MEDICATIONS, TREATMENT

I give permission for full participation in CAP programs, subject to any limitations noted herein.

My signature below evidences my consent for my child/ward to possess and self-administer the prescription medications listed above I understand that there are legal limitations imposed on CAP senior members with regard to the involuntary administration of medications to my child/ward. (Cross out if permission is denied).

In case of emergency, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the licensed health-care practitioner selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge exam/test results and treatment provided.

___________________________

________________________________________________________________________________________________________

DATE

SIGNATURE OF PARENT/GUARDIAN

CAP Form 160 Reverse

How to Edit Capf 160 Form Online for Free

The PDF editor was created with the aim of allowing it to be as effortless and intuitive as possible. All of these actions will make creating the capf 160 pdf easy and quick.

Step 1: The following webpage has an orange button that says "Get Form Now". Merely click it.

Step 2: The form editing page is now open. You can include text or enhance current data.

Complete the capf 160 pdf PDF and enter the content for every area:

filling in capf 160 step 1

Write down the requested details in Decreased vision glaucoma contacts, Irregular or rapid heartbeat High, Chronic or recurring injuries, CAPF JUN, and OPRROUTING HS box.

Finishing capf 160 stage 2

The program will require you to insert some necessary info to instantly fill in the part Dietary Restrictions or, Past Surgical History List all, Date Tetanus Booster, Hepatitis Vaccine, No Td or Tdap, Date, Date, Pneumonia Vaccine No, Date, Varicella Immuni zationchickenpox, Influenza Vaccine, Date, Date, Medication Information Include, and Name of MedicationInhaler.

Filling out capf 160 part 3

You will need to identify the rights and responsibilities of every party in part Tobacco Use packs per day years, Occupation student or other, Religious Preference, Social History, Remarks Attach additional sheet if, CONSENT FOR MINOR CADET, I give permission for full, My signature below evidences my, and In case of emergency I understand.

capf 160 Tobacco Use packs per day years, Occupation student or other, Religious Preference, Social History, Remarks Attach additional sheet if, CONSENT FOR MINOR CADET, I give permission for full, My signature below evidences my, and In case of emergency I understand fields to insert

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