New Mexico Military Institute - Medical Health and Consent
Applicant Information
First Name
Last Name
Email
Phone
Social Security Number (SSN)
Gender
Please select...
Female
Male
Applicant Date of Birth:
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Year
Please select...
2000
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Parent or Legal Guardian Information
First Name
Last Name
Phone
Email
Relationship
First Name
Last Name
Phone
Email
Relationship
Is the applicant a military dependent?
Yes
No
If "Yes" give sponsor's SSN:
Please select option below of military insurance coverage:
TRICARE Standard
TRICARE Prime (Charleston PCM Only)
Medical History
Do you have a history of any of the following?
Dizziness, loss of consciousness, or fainting
High blood pressure or stroke
Hay fever or seasonal allergies
Reactions to medications, foods, or bugs
Surgery, or consult with surgeon
Frequent or severe headaches or migraines
Dental pain, tooth or gum problems
Epilepsy, seizures, convulsions or fits
Scarlet fever or rheumatic fever
Tumors, cysts, unusual growths or cancer
Visit to a Cardiologist or heart specialist
Chest pain, pressure or palpitations
Hearing problems (murmur, rhythms)
Shortness of breath with excerise
Asthma (reactive airways), recurrent wheeze
Chronic cough, lung disease or bronchitis
Tuberculosis or close contact with persons
Diabetes, blood sugar too high or low
Stomach, liver, gall bladder problems
Hepatitis, jaundice, liver problems
Gastroesophageal reflux/GERD
Intestinal disease (Crohn's disease, UC)
Coughed up blood or vomited blood
Hemorrhoids or rectal disease
Black or bloody stools
Kidney stones, kidney infections or problems
Frequent or painful urination
Blood in urine
Hernia or rupture
Eating disorder (anorexia, bulimia)
Significant illness or surgery not listed
Eye problems or vision changes
Wears glasses or contacts
Hearing loss
Recent ear infections
Visit to a rheumatologist
Frequent persistent colds
Sinus infections or sinusitis
Mouth or nose problems
Tooth or gum problems
Thyroid or throat problems
Problems w/testicles, scrotum or penis
Problems with menses, breast or pap smear
Muscle weakness, paralysis or lameness
Painful or swollen joints
Dislocations
Bone problems or bone fractures
Back or neck pain
Wears a brace or splint
Bone or joint deformity
Leg cramps
Persistent foot pain
Skin problems
Excessive bleeding, easy bruising or clotting
Visit to a hematologist or oncologist
Any current wounds
None of the above
If any of the above was marked "YES" please provide an explanation:
Please check off any symptoms or diagnosis you are currently experiencing or have experienced:
Attempted suicide
Thoughts of suicide
Depression
Anxiety
Excessive worrying
Bipolar disorder
Schizophrenia
Psychosis
ADD/ADHD learning disability
Any speech disabilites
Visit to a psychiatrist, counselor or therapist
History of self-harm or "cutting"
I have never had any of the above symptoms or diagnosis's.
If any of the above were selected, please provide an explanation and date of occurrence:
Are you taking any medications?
Please select...
Yes
No
Please list the medications you are currently taking and include dosage and diagnosis for
EACH:
Are you allergic to any medications?
Please select...
Yes
No
Please list the medications you are allergic to:
Is there anything else you'd like to tell us?
Influenza Vaccination: Please select an option below: By selecting "yes" to consent, "
You authorize NMMI infirmary to administer the influenza vaccines on a yearly basis while the applicant is attending NMMI. In the event of an infectious disease outbreak, i.e. influenza, etc. NMMI will coordinate parental notification of those cadets without parental authorization through local public health agencies. Cadets refusing mandatory immunization during an outbreak may be immediately dis-enrolled from NMMI upon counsel of the New Mexico Department of Health
"
Please select...
I DO GIVE CONSENT FOR THE INFLUENZA VACCINE
I DO NOT GIVE CONSENT FOR THE INFLUENZA VACCINE
The following are some examples of chronic conditions which will be reviewed by the NMMI Medical Board before final acceptance is granted. In all cases, a candidate should be expected to fully participate with the Corps of Cadets without concern for their safety or the safety of others due to such a chronic condition. Please select any of these that apply to you.
Epilepsy or previous seizures with current treatment
Diabetes requiring special diet and insulin therapy
Blindness
Deafness
Chronic renal disease
Chronic cardiac disease
Severe symptomatic asthma
Any severe neuromuscular or orthopedic disease which would interfere with the cadet's performance and physical activity in accordance with NMMI requirements
Any attempted suicide
Manic depressive disorder, bipolar disorder, regularly scheduled psychological counseling or any other severe psychological disorders or limiting condition which in the opinion of medical staff interferes with the cadet's ability to function satisfactorily at NMMI or demonstrates an inability to meet the existing NMMI admission requirements without significant accommodation that would alter the mission of the institute.
Drug addictions or alcohol addictions
None of above
Consent:
"I do hereby give permission to New Mexico Military Institute - Marshall Infirmary health care professionals and/or NMMI contracted health care staff - to treat my son/daughter/myself on a routine and emergency basis. I also authorize the New Mexico Military Institute employed or contracted health care professions to refer my son/daughter/myself to an appropriate local health care facility/office in the Roswell community, the Eastern New Mexico Medical Center or Lovelace Regional Hospital for further evaluation, treatment, or hospitalizations as deemed necessary. I understand that failure to disclose all current/or previous medical, physical and mental conditions could result in denial of admission and will be grounds for medical review and possible termination of your cadet career with forfeiture of appropriate tuition and fees."
Please select...
Yes, I agree with the above statement.
No, I do not agree to the above statement
Cadets must complete all physical aspects of the Recruit of Training Period (first 21 days of school).
This includes running, sit-ups, push-ups, running up and down stairs, rifle manual, marching in formation and a variety of other physical activities. Because initial cadet training is only offered once, Cadets who miss more than 30% of this training period due to injury or illness will be referred for medical review and possible medical discharge for the semester.
Please select...
Yes, I agree that all the information provided is accurate and applicant CAN FULLY participate in all activities.
No, the information provided is not accurate and the applicant CANNOT FULLY participate in all activities
Applicant - Please type your full name below to confirm that all the information provided is accurate and complete.
Date (MM/DD/YY)
Guardian- Please type your full name below to confirm that all the applicant's information provided is accurate and complete.
Date (MM/DD/YY)
Phone
Email
Address, City, State, Zip
In the event you would like to call the infirmary to receive information about your cadet, please provide a PASSWORD for your cadet's protected health information (this could be any phrase or number that you can easily remember):
** Foreign medications are NOT allowed at NMMI. All prescription medications must be US prescriptions.
Contact Information