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Learn and Explore
About Us
Values and Standards
Key Personnel/Command Structure
Join Us
Training and Leadership Opportunities
Careers
Coast Guard
Band & Corps of Drums
Junior Leaders
News and Events
Information & Publications
Contact
Log In
Next intake
: February 2026.
Application deadline
: January 2026
Recruitment Medical Statement
First Name
Middle Name
Last Name
DOB
MM slash DD slash YYYY
Email
Do you have health insurance?
Yes
No
Have you been hospitalized for a mental health disorder?
Yes
No
Could you be pregnant, or are you attempting to become pregnant?
Yes
No
Do you take and prescription medications? (with the exception of birth control or anti-material)
Yes
No
Can YES to one or more of the following?
currently smoke a pipe, cigars or cigarettes
have a high colesterol level
have a family history of heart attack or stroke
are currently receiving medical care
high blood pressure
diabetes mellitus, even if controlled by diet alone
List your vaccinations and dates if known:
VACCINATION
DATE (MM-YYYY)
Add
Remove
Click the plus (+) icon on the right to add more fields
Have you ever had or do you currently have:
Asthma, or wheezing with breathing, or wheezing with exercise?
Yes
No
Frequent or severe attacks or hayfever or allergy?
Yes
No
Frequent colds, sinusitis, or bronchitis?
Yes
No
Any form of lung disease?
Yes
No
Pneumothorax (collapse lung)?
Yes
No
Other chest disease or chest surgery?
Yes
No
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?
Yes
No
Epilepsy, seizure, convulsions or take medications to prevent them?
Yes
No
Recurring complicated migraine headaches or take medications to prevent them?
Yes
No
Blackouts or fainting (full/partial loss of consciousness)?
Yes
No
Dysentery or dehydration requiring medical intervention?
Yes
No
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?
Yes
No
Head injury with loss of consciousness in the past five years?
Yes
No
Reccurent back problems?
Yes
No
Back or spinal surgery?
Yes
No
Diabetes
Yes
No
Back, arm or leg problems following surgery, injury or fracture?
Yes
No
High blood pressure or take medicine to control blood pressure?
Yes
No
Heart disease?
Yes
No
Heart attack?
Yes
No
Angina, heart surgery or blood vessel surgery?
Yes
No
Sinus surgery?
Yes
No
Ear disease or surgery, hearing loss or problems with balance?
Yes
No
Recurrent ear problems?
Yes
No
Sickle Cell Anemia, bleeding or other blood disorders?
Yes
No
Hernia?
Yes
No
Ulcers or ulcers surgery?
Yes
No
A colostomy or ileostomy?
Yes
No
Recreational drug use or treatment for, or alcholism in the past five years
Yes
No
Do you have any allergies (food/Bee stings / General)?
Yes
No
Have you suffered partial or full loss of vision in any eye? Do you have any eye condition?
Yes
No
Are you color blind?
Yes
No
Kidney or urinary problems?
Yes
No
Blood group (if known):
Give the name of your personal doctor:
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