Name		Optional
Age		16-25 26-35 36-45 46-55 56-65 66-75 76-85 86-95       Gender male female
E-mail Address		Valid e-mail required
Phone		Optional
Have you been denied,                      suspended or revoked for fitness or medical reasons?   No Yes
		If "YES", please give details below.
		Current Fitness Level   Sedentary Exercise Vigerously 2-4 days per wk Exercise Vigerously 5 or more days per week
		Date of last application   No prior application

Medication		Dosage	Condition Treated
Detail any loss of consciousness, injuries, major surgeries, or other condition which might limit physical activity or law enforcment.
Select all below which applies (Explain in the box below)
		Frequent or severe headaches
		Eye or vision trouble
		Hay fever or allergy
		Asthma or lung disease
		Stomach, liver, or intestinal trouble
		Kidney stone or blood in urine
		Neurological: epilepsy, seizures, stroke, etc
		Mental disorders: depression, anxiety, etc
		Dependence or use of illegal substance
		Alcohol dependence, abuse or related convictions
		Suicide attempt
		Motion sickness requiring medication
		Dizziness, fainting spells, or unconsciousness
EXPLAIN
		Diabetes? No diabetes Taking injections On oral medication Controlled by diet
		HEART HISTORY
		Myocardial Infarction (Heart Attack)
		Angina, bypass, angioplasty
		Stroke / blood vessel surgery
		Other heart condition    List
Blood Pressure Normal High Low Don't know