New Mexico National Guard Youth ChalleNGe Academy. Medical Packet

Transcription

1 New Mexico National Guard Youth ChalleNGe Academy Medical Packet

2 Medical Packet Components: Medical packet should be completed after submission of application. Medical History Questionnaire Physical Form (To be completed by primary care physician) TB Screen Form Behavioral Health Questionnaire Behavioral Health Records Request Current Eye Exam (Letter from Dr. that exam is current) Current Dental Exam (Letter from Dr. that exam is current) Medical Statement of Understanding

3 New Mexico National Guard Youth ChalleNGe Academy Medical History Questionnaire **Please keep in mind that any information that is NOT disclosed at the time of submission of the application, and is found to be a previous injury/illness, could be grounds for medical dismissal from the program. ** Please fill out the following information to the best of your ability: Cadet Name: DOB: SSN: Insurance Carrier: MEDICAID PRIVATE Family Physician Name: If Private, Subscriber Name, DOB, SSN: Number: Past Medical History Have you (applicant) ever had any of the following: Please circle yes or no 1. Severe Headaches Yes No 13. Thyroid Problems Yes No 2. Seizures Yes No 14. Depression/Anxiety Yes No 3. Blackout Spells Yes No 15. Skin Disorder Yes No 4. Head Injury Yes No 16. Allergies Yes No 5. Asthma/Breathing Problems Yes No 17. High Blood Pressure Yes No 6. Severe Heartburn Yes No 18. Heart Murmur Yes No 7. Hernia Yes No 19. Behavior Problems Yes No 8. Frequent Kidney Infections Yes No 20. Untreated Injury/Illness Yes No 9. Frequent Urinary Tract Inf. Yes No 21. Injury related to fall Yes No 10. ADD/ADHD Yes No 22. Injury related to car accident Yes No 11. Hearing Loss Yes No 23. Injury requiring surgery Yes No 12. Vision Problems Yes No 24. Other injuries/illnesses Yes No If you answered YES to any of the above questions, please list the number and provide an explanation: Please answer the questions on the following page as truthfully as possible:

4 1. Have you been in a treatment or mental facility within the last 6 (six) months? YES NO If yes, please explain how long you were there and the reason. FILL OUT BEHAVIORAL HEALTH QUESTIONNAIRE. 2. Are you currently or have you ever been under the care of a counselor or psychiatrist? YES NO If yes, please explain. PROVIDE BEHAVIORAL RECORD REQUEST LETTER TO PROVIDER. 3. Are you currently taking any medications? YES NO If yes, please list them and what they are taken for: 4. Are you allergic to any foods or medicines? YES NO If, yes, please list them and what the reaction is: 5. Do you wear, or are you supposed to wear prescription glasses or contacts? YES NO If yes, do you have a current prescription and/or glasses/contacts? YES NO 6. Do you have any DENTAL issues we need to know about? YES NO If yes, please explain: Braces/Retainer: YES NO Last Adjustment: 7. Do you have asthma or use an inhaler? YES NO If yes, please ensure you bring one with you. 8. Do you take medication daily? YES NO If yes, please ensure you have enough to last 22 weeks (written scripts or refills) 9. Are there any medical issues or concerns we need to be aware of? (Injuries, Illness, etc) YES NO If yes, please explain: APPLICANT PRINTED NAME APPLICANT SIGNATURE PARENT/GUARDIAN PRINTED NAME PARENT/GUARDIAN SIGNATURE

5 New Mexico National Guard Youth ChalleNG e Academy Physical Examination Form This form should be filled out by applicants Primary Care Physician Last Name: First Name: Birthdate: SSN: Date Exam Completed: Height: Weight Vitals: Temp Pulse Resp BP General Appearance: EXAMINATION: Are there any PRE-EXISTING injuries/illnesses that NMNGYCA should be aware of: Eyes/Ears/Nose/Throat Lymph Nodes Heart Pulses Lungs Abdomen skin Neck Back Shoulder/Arm Elbow/Forearm Wrist/Hands Hip/Thigh Knees Leg/Ankles Feet Breast (Female) Genitalia (Males) TB Skin Test Given Flu Vaccine Given PHYSICAL EXAMINIATION Normal Abnormal/Findings Initials Date: Results: Date Read: Date: Manufacturer: Lot #: Exp: PHYSICALLY QUALIFIED. The patient is cleared to participate in all forms of physical activity to include but not limited to: running, marching, push-ups, sit-ups, pull-ups. NOT PHYSICALLY QUALIFIED. The patient is not physically qualified to particiapte in the above physical activities due to findings listed above. Physician Printed Name Physician Signature Phone Number

6 New Mexico National Gaurd Youth ChalleNGe Academy Medical Department 131 Earl Cummings Loop Roswell, NM Step Tuberculin Test (Mantoux) Name of patient: Date 1 st test administered: Date 1 st test read: Result: Date 2 nd test administered: Date 2 nd test read: Result: OR ATTACH DOCUMENTATION OF THE TEST AND TEST RESULTS TO THIS FORM. Signature of physician or nurse: Date: Phone number: *Students enrolled into NM National Guard Youth ChalleNGe Academy are required to be screened for TB to ensure they are not carrying the infectious disease due to close quarters living. Students also participate in various activities that require TB test for participation (i.e. participation in CNA clinical for their vocational class). If you have any questions regarding TB screening, please contact the Medical Dept at NM National Guard Youth ChalleNGe Academy.

7 New Mexico National Guard Youth ChalleNGe Academy 131 Earl Cummings Loop Roswell, NM Behavioral Health Questionnaire Applicant: If you have ever received mental health services or have been hospitalized for behavioral health reasons, you will need to provide additional information with your application. Below is a questionnaire to assist you in determining if this is necessary. Please note, any information not disclosed at the time of the application could lead to medical dismissal if discovered after enrollment. Disclosure of behavioral health information will not automatically disqualify you. Please answer the questions truthfully. 1. Have you ever been diagnosed and/or treated by a therapist/psychiatrist for any of the following: a. Anger Management Issues Yes No b. Anxiety Yes No c. Bipolar Disorder Yes No d. Conduct Disorder Yes No e. Dissociative Disorder Yes No f. Oppositional Defiant Disorder Yes No g. Panic Attacks Yes No h. Post-Traumatic Stress Disorder Yes No i. Schizophrenia Yes No j. Violent Outbursts Yes No k. Other Yes No 2. Have you ever been hospitalized for suicidal thoughts or attempts? Yes No If yes, please explain. 3. Have you ever been prescribed medication for mental health reasons, regardless of whether or not you took them? Yes No If you answered YES to any of the above questions, you will need to obtain a letter from a Behavior Health Provider. Please see next page for instructions. By signing below, you ensure to the best of your knowledge, that all information provided is true and accurate. Applicant Signature Date Parent/Guardian Signature Date

8 New Mexico National Guard Youth ChalleNGe Academy 131 Earl Cummings Loop Roswell, NM Toll Free Fax Behavioral Health Record Request *Applicant Please present this letter to your Behavioral Health Care Provider for assistance in securing the records needed to be considered for acceptance into the NMNGYCA. Dear Provider, The client presenting this letter is applying for enrollment into the NM National Guard Youth ChalleNGe Academy. The NMNGYCA is a 5 ½ month residential program with a quasi-military structure, strict adherence to discipline, rules and regulations and encompasses a high-stress environment. The cadets live in open-bay dorms with approximately others and attend school daily. Cadets wake up daily at 6 a.m. to participate in physical exercise, will complete a minimum of 40 hours of service to community, and if successful, earn a GED along with a Certificate of Employment in a vocational trade. If you would like to learn more about our program, please visit our website. As part of the application process, each applicant must provide documentation that they are physically and mentally capable of participation in the program. If you are receiving this letter, that means the applicant has been diagnosed with or has/is being treated for a mental health issue. Please provide the applicant with documentation addressing the following: Applicant s current diagnosis and/or former diagnosis, if applicable. Treatment plan for applicant to include: frequency of sessions, goals, client s progress, coping/strategies, stress reduction plan, identified triggers, etc. Any corresponding psychiatric services to include: current medications and dosages, history of medication management, applicant s responsiveness to medication, etc. Treating therapist/psychiatrist s professional opinion on the mental/emotional stability of the applicant and his/her ability to complete the program. Please note, NMNGYCA is not equipped to provide on-going mental health counseling services. However, brief intervention and guidance counseling services are provided. If you have any questions regarding the information being requested, please do not hesitate to contact us. Thank you in advance for your cooperation. Sincerely, Sabrina Lara Sabrina Lara Recruiting, Placement & Mentoring Supervisor NMNGYCA Sabrina.lara@roswell.enmu.edu

9 New Mexico National Guard Youth ChalleNGe Academy 131 Earl Cummings Loop Roswell, NM Medical Statement of Understanding I/We, the parent/legal guardian of understand that my child, while enrolled in NMNGYCA, must have current and valid medical insurance. I understand that the NMNGYCA DOES NOT provide medical insurance for cadets and that I must ensure that coverage is maintained while my child is enrolled in the program. I further understand that the $120 I provide can/will be used for medical expenses such as doctor visit co-pays and medication co-pays but these expenses cannot exceed $60. If medical expenses exceed this amount, I understand that I am responsible for ensuring the expense is paid. I also understand that if medical insurance cannot be maintained, my child could be dismissed from the program, unless financial arrangements are made with the medical provider. I also understand that my child must be medically cleared prior to participation in the program and that all medical conditions (injuries, illnesses, special requirements) must be disclosed. If information is not disclosed during the application process, and issues arise because of conditions not disclosed, your cadet could be medically dismissed until he/she can be cleared to participate, which will require reapplying for the next cycle. Date signed Parent/Guardian Printed Name Phone Number Insurance type (please circle insurance carrier): MEDICAID PRIVATE INSURANCE OTHER Company: Policy Holder Information Explain: Name DOB SSN