Enclosure (3) to COMDTINST 16798.2
Substance Dependence and Substance Abuse - Absence of a diagnosis
of Substance dependence or established evidence of recovery,
including total Abstinence from the substance(s) for not less than
the preceding 2 years. ("Substance" includes alcohol, PCP,
sedatives, hypnotics, anxiolytics, marijuana, cocaine, opioids,
Yes
No
amphetamines, hallucinogens, and other psychoactive drugs or
chemicals.)
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___
Disqualifying Conditions - History of:
Yes
No
1.
Diabetes Mellitus requiring medication
___
___
2.
Angina Pectoris
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___
3.
Coronary heart disease being treated, is symptomatic
or clinically significant
___
___
4.
Myocardial Infarction
___
___
5.
Cardiac Valve Replacement
___
___
6.
Permanent Cardiac Pacemaker
___
___
7.
Heart Replacement
___
___
8.
Epilepsy
___
___
9.
Disturbance of Consciousness
___
___
(without satisfactory explanation of cause)
10. Transient Loss of Control of Nervous System Functions
___
___
(without satisfactory explanation of cause)
Comments:
Signed_____________________________________________M.D./D.O
Name_______________________________________________
Address____________________________________________
Phone___________________________
ANSC 7042
3
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