PAC
Personal Information:
Full Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date Of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Sex
Please Select
Male
Female
Phone Number
*
-
Area Code
Phone Number
Height/Weight
*
Inches/Lbs
Have you ever taken one of the following:
*
ACT
ASVAB
SAT
None of the Above
Questions and Details:
Have you ever had any police involvement? (Arrest, tickets, misdemeanors, diversions, etc)
*
Have you ever taken a drug? (MJ, ACID, EX, Mushrooms, Coke, Bath Salts, etc)
*
Do you currently or ever had: Implants, screws, bolts, or pins in your body?
*
Do you currently or ever had to wear contacts or glasses?
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Have you ever had an operation? (Wisdom teeth, tonsils, appendicitis, etc)
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Have you ever taken any medication? (ADHD, ADD, Depression, Blood pressure)
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Have you ever broken a bone or suffered a fracture?
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Have you ever been diagnosed by a doctor for Asthma or any other breathing problem?
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Have you ever had any tattoos, brandings, or piercings anywhere on your body ?
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If yes: Where? What is it? How big? What does it mean?
Do you have normal depth perception? Are you colorblind? Do you have any eye conditions?
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Have you ever had any hearing problems? Have you ever had tubes in your ear?
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Have you ever been diagnosed by a doctor for any allergy? (Nuts, insect stings, medication)
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Have you ever been seen by a counselor, psychiatrist, or physiologist?
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If yes: For what? How long ago?
Have you ever spent the night in the hospital for any reason?
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Have you ever visited an Emergency Room? Have you ever visited a Chiropractor?
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Have you ever had to get staples or stitches? Do you have any noticeable scars on your body?
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Have you ever had or currently have any moles, warts, or cysts?
*
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