Ohmr Form 88 PDF Details

Are you starting a business and feeling overwhelmed by all the paperwork? Filling out Form 88 to register your brand isn't an easy task. But don't worry—we're here to show you how it's done! We'll provide step-by-step instructions on completing Ohmr's Form 88, so that registering your business is stress-free. With our simple guide, you can make sure everything runs smoothly when submitting this important document. So let's get started!

QuestionAnswer
Form NameOhmr Form 88
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesohmr88 ohmr form 88a

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OHIO MILITARY RESERVE

REPORT OF MEDICAL HISTORY

(THIS INFORMATION IS FOR OFFICIAL AND MEDICALLY-CONFIDENTIAL USE ONLY AND WILL NOT BE RELEASED TO UNAUTHORIZED PERSONS)

1. LAST NAME-FIRST NAME-MI:

 

2. SOCIAL SECURITY OR IDENTIFICATION NO.

 

 

 

 

3.

HOME ADDRESS (No. street or RFD, city or town, State, and ZIP CODE)

4. POSITION (title, grade)

 

 

 

 

5.

PURPOSE OF EXAMINATION

6. DATE OF EXAMINATION

7. EXAMINING FACILITY OR EXAMINER, AND ADDRESS

 

 

 

 

8.STATEMENT OF EXAMINEES PRESENT HEALTH AND MEDICATIONS CURRENTLY USED

9. HAVE YOU EVER (Please cheek each item)

 

 

 

 

10. DO YOU (Please check each item)

YES

 

NO

 

(Check each item)

 

 

 

 

YES

 

NO

 

(Check each item)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lived with anyone who had tuberculosis

 

 

 

 

 

 

 

 

Wear glasses or contact lenses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Coughed up blood

 

 

 

 

 

 

 

 

Have vision in both eyes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bled excessively after injury or tooth extraction

 

 

 

 

 

 

 

 

Wear a hearing aid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attempted suicide

 

 

 

 

 

 

 

 

Stutter or stammer habitually

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Been a sleepwalker

 

 

 

 

 

 

 

 

Wear a brace or back support

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. HAVE YOU EVER HAD OR HAVE NOW (Please check at left of each item)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

DON'T

(Check each item)

 

YES

NO

DON'T

(Check each item)

YES

 

NO

 

DON'T

(Check each item)

 

 

 

 

KNOW

 

 

 

 

KNOW

 

 

 

 

 

KNOW

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Scarlet fever, erysipelas

 

 

 

 

Cramps in your legs

 

 

 

 

 

"Trick" or locked knee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rheumatic fever

 

 

 

 

Frequent indigestion

 

 

 

 

 

Foot trouble

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Swollen or painful joints

 

 

 

 

Stomach, liver, or intestinal trouble

 

 

 

 

 

Neuritis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Frequent or sever headache

 

 

 

 

Gall bladder trouble or gallstones

 

 

 

 

 

Paralysis (Including Infantile

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dizziness or fainting spells

 

 

 

 

Jaundice or hepatitis

 

 

 

 

 

Epilepsy or fits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eye trouble

 

 

 

 

Adverse reaction to serum, drug, or

 

 

 

 

 

Car, train, sea or air sickness

 

 

 

 

 

 

 

 

 

medication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ear, nose or throat trouble

 

 

 

 

Broken bones

 

 

 

 

 

Frequent trouble sleeping

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hearing loss

 

 

 

 

Tumor, growth, cyst, cancer

 

 

 

 

 

Depression or excessive worry

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chronic or frequent colds

 

 

 

 

Rupture/hernia

 

 

 

 

 

Loss of memory or amnesia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Severe tooth or gum trouble

 

 

 

 

Piles or rectal disease

 

 

 

 

 

Nervous trouble of any sort

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sinusitis

 

 

 

 

Frequent or painful urination

 

 

 

 

 

Periods of unconsciousness

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hay fever

 

 

 

 

Bed wetting since age 12

 

 

 

 

 

Stroke

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Head injury

 

 

 

 

Kidney stone or blood in urine

 

 

 

 

 

Diabetes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Skin diseases

 

 

 

 

Sugar or albumin in urine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Thyroid trouble

 

 

 

 

VD-Syphilis, gonorrhea, etc.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tuberculosis

 

 

 

 

Recent gain or loss of weight

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Asthma

 

 

 

 

Arthritis, Rheumatism or Bursitis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Shortness of breath

 

 

 

 

Bone, joint or other deformity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pain or pressure in chest

 

 

 

 

Lameness

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chronic cough

 

 

 

 

Loss of finger or toe

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Palpitation or pounding heart

 

 

 

 

Painful or "trick" shoulder or elbow

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heart trouble

 

 

 

 

Recurrent back pain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

High or low blood pressure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. WHAT IS YOUR USUAL OCCUPATION?

OHMR FORM 88 (JAN 07)

YES NO CHECK EACH ITEM YES OR NO. EVERY ITEM CHECKED YES MUST BE FULLY EXPLAINED IN BLANK SPACE ON RIGHT

13. Have you been refused employment or been unable to hold a job or stay in school because of:

A. Sensitivity to chemicals, dust, sun light, etc.

B. Inability to perform certain motions.

C. Inability to assume certain positions.

D. Other medical reasons (if yes, give reasons)

14. Have you ever been treated for a mental condition? (If yes, specify when, where, and give details.)

15. Have you ever been denied life insurance? (If yes, state reason and give details.)

16. Have you had, or have you been advised to have any operations? (If yes, describe and give age at which occurred.)

17. Have you ever been a patient in any type of hospital? (If yes, specify when, where, why, and name of doctor and complete address of hospital.)

18. Have you ever had any iIIness or injury other than

those already noted? (If yes, specifically when, where, and give details.)

19. 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, clinic, and details.)

20. Have you ever been rejected for military service because of physical, mental, or other reasons?

(If yes, give, date and reason for rejection.)

21. Have you ever been discharged from military service because of physical, mental, or other reasons?

(If yes, give date, reason, and type of discharge: whether honorable, other than honorable, for

unfitness or unsuitability.)

22. 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, and what amount, when, why.)

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 authorize any of the doctors, hospitals, or clinics mentioned above to furnish the OHIO MILITARY RESERVE a complete transcript of my medical record for purposes of processing my application for this employment or service.

TYPED OR PRINTED NAME OF APPLICANT:

SIGNATURE:

23. ADDITIONAL COMMENTS:

24. HEIGHT

25. WEIGHT

 

26. COLOR HAIR

27. COLOR EYES

28. BUILD: (CHECK ONE)

 

 

 

 

 

 

 

A. SLENDER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. MEDIUM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. HEAVY

29. TEMPERATURE:

 

30. BLOOD PRESSURE: (Arm at Heart Level)

 

31. PULSE: (Arm at Heart Level)

 

 

 

 

 

 

 

 

 

32.SITTING

33.RECUMBENT:

34.STANDING (3 MIN)

35.SITTING

36.AFTER EXERCISE

37.2 MIN AFTER

38.RECUMBENT

39.RESPIRATION:

40.BLOOD TYPE:

41.RELIGION:

42.TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER:

43.DATE:

44.SIGNATURE:

45.NUMBER OF ATTACHED SHEETS:

OHMR FORM 88 (JAN 07) REVERSE SIDE

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