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Information Sheet

Last Name: __________________ First Name: _____________________


Date of Birth: ______________ Age: ____ Height: ____ Weight: ______
Social SecurityNumber: ___-__-___ Phone number: ___-___-____
Troop: ___ Platoon: ___________ MOS: __________
Profile: Y/N If so, ( ) Temporary ( ) Permanent
If profile is Temporary Starting date ____________ and Ending date __________
If profile is Permanent Circle one: P1 P2 P3
What is the profile for? (Limitations) ____________________________________
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Medicines Allergies: _________________________________________________
Regular Allergies: ___________________________________________________
Medications: _______________________________________________________
Past Medical Conditions: _____________________________________________
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Do you? Drink Alcohol Y/N Smoke Tobacco Y/N Chew Tobacco Y/N