AMEDDApplicantWorksheet-July2012-3.doc

Shoulder knee or elbow problem out of place 66

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Shoulder, knee, or elbow problem (out of place) 66. Locking of the knee or other joint 67. Giving way of knee or other joint 68. Cataracts or surgery for cataracts 69. Eye surgery, including radical keratotomy, lens implant or other eye surgery to improve your vision 70. Collapsed lung or other lung condition 71. Bed wetting since age 12 72. Evaluation, treatment, or hospitalization for alcohol abuse, dependence, or addiction 73. Do you use any tobacco products Type (Cigarette, Cigar, Smokeless Tobacco): Date last used (dd-MMM-yyyy): 74. Evaluation, treatment, or hospitalization for substance use, abuse, addiction or dependence (including illegal drugs, prescription medications, or other substances) 75. Taken medication, drugs, or any substance to improve attention, behavior, or physical performance 76. Any illness, surgery, or hospitalization not listed above 77. Do you have a current insurance provider Name: Policy No.: Street address, City, State, Zip Code, Country: 78. Have you had a previous insurance provider Name: Policy No.: Street address, City, State, Zip Code, Country: 79. Do you have a primary care physician provider Name: Street address, City, State, Zip Code, Country: Country Code: Telephone No.: ( ) - Extension: 80. Have you had a previous primary care physician Name: Street address, City, State, Zip Code, Country: Country Code: Telephone No.: ( ) - Extension: 81. Painful or 'trick' joints or loss of movement in any joint 82. Do you have any tattoos or body piercings List : 83. Any deformities of, or missing fingers or toes 9
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Additional Medical Info Include question number and explain all ‘YES’ answers that apply to include the following information: From-To Date(s) in (dd-MMM-yyyy) format, Age, Doctor’s Last name, Explanation, and Treatment Facility Information (Name, Street address, City, State, Zip Code). 10
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PERSONAL SCREENING QUESTIONNAIRE Complete all questions. If additional information is required for ‘YES’ answers given, the question requiring additional information will be specified. Refer to the end of the Personal Screening Questionnaire section for additional space if needed. Y/N 1. Have you ever been divorced? 2. Are you legally separated? 3. Are you married? 4. Have you ever been married? 5. Do you presently reside with a cohabitant? 6. Have you used any other names? 7. Have you fathered/mothered any children? How many? 8. Is anyone dependent upon you for financial support? How many? 9. Do you have custody of any minor children? How many? 10. Are you now or have you ever been negligent in providing alimony or support for children? 11. Have you served in any branch of Armed Services to include the National Guard? 12. Been rejected for military service (temporary or permanent) for medical or other reasons Date (dd-MMM-yyyy): Explanation: 13. Do you have an immediate relative (father, mother, brother or sister) who: is now a prisoner of war or is missing in action (MIA); or died or became 100% permanently disabled while serving in the Armed Services?
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