Attachment_1.rtf

CDC Responder Readiness Medical Clearance

Name: __________________________________Date: ____________ Social Security Number: ______________________________________ The information you provide in this clearance exam is private and confidential.

Past Medical and Surgical History (List any past or current medical complaints, diseases, symptoms, surgeries, procedures or other conditions) Date Condition Current Status

Family History (List any medical conditions of blood relatives including high blood pressure, heart or kidney disease, diabetes, cancer, alcoholism, psychiatric illness or others)

Social History Do you use tobacco in any form? No Yes Do you drink alcohol in any form? No Yes Do you use illegal drugs or misuse other drugs? No Yes

Explain any “yes” answers. ________________________________________________________________________________________________________________________________________________

Assessment of Physical Activity Level (Describe type, amount and frequency of physical activity that you complete on a regular basis.) __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Current Medications (Include prescription, over-the-counter, vitamins, supplements, herbals, others)

Allergies (List and describe medication, food, insect or other allergic reaction or adverse event)

Name: _________________________________ Date: _____________

Immunization History (Give month and year when immunization(s) last completed if known)

Tetanus/Diphtheria _______________________________________ Hepatitis A _____________________________________________ Hepatitis B _____________________________________________ Measles/Mumps/Rubella __________________________________ Varicella (if unknown, must titer) _________________________________ Anthrax ________________________________________________ Smallpox _______________________________________________ TB Skin Testing__________________________________________

Review of Symptoms in Major Body Systems

HAVE YOU EVER HAD:

YES

NO

YES

NO

1. Frequent or severe headaches?

26. Kidney or prostate disease?

2. Dizzy spells, fainting or blackouts?

27. Diabetes?

3. Epilepsy or seizures?

28. Thyroid disease?

4. Eye trouble or vision problems?

29. Other endocrine disease?

5. Ear problems or difficulty hearing?

30. Heavy menstrual bleeding?

6. Hay fever or other allergies?

31. Anemia/ hematological disorder?

7. Dental problems?

32. Easy bruising or bleeding?

8. Other ear, nose or throat problems?

33. Blood clots?

9. Wheezing or asthma?

34. Arthritis/ joint pains/swelling?

10. Shortness of breath on exertion?

35. Other connective tissue disease?

11. Chronic cough?

36. Joint or bone deformity/fracture?

12. Coughing up blood?

37. Back pain; wear a back brace?

13. Tuberculosis or (+) Tb skin test?

38. Difficulty walking?

14. Pain or pressure in your chest?

39. Eczema or atopic dermatitis?

15. Palpitations or pounding heart?

40. Other rashes?

16. Heart murmur?

41. Any other skin diseases?

17. Other heart problems?

42. Cancer?

18. High or low blood pressure?

43. Any immune system disorder?

19. Frequent indigestion/heartburn?

44. Chronic steroid treatment?

20. Stomach or intestinal problems?

45. Other immunosuppressive drugs?

21. Hepatitis or liver disease?

46. Nerve injury or paralysis?

22. Rupture or hernia?

47. A sleep disorder?

23. Rectal bleeding or discharge?

48. Easy fatigability?

24. Frequent urination?

49. Depression or crying spells?

25. Kidney stones?

50. Other psychiatric problems?

Give details of any “yes” answers above and comment on the current status of symptoms.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________List and describe any other medical problem, symptom or concern not addressed above. ________________________________________________________________________________________________________________________________________________

For women only: Are you currently pregnant? No Yes Date of last menstrual period: _____________ Name: ___________________________________ Date:_____________

Please read and sign the following statement. If you feel you need additional information or have any questions regarding the medical risks of deployment or questions regarding the medical clearance process, please ask the CDC Occupational Health Clinic medical staff.

Deployment on a CDC/ATSDR emergency response team could involve physical and emotional stressors and hazards, including but not limited to:

• rapid deployment to any location upon short notice

• deployment lengths lasting weeks to months

• separation from family and friends

• personal security issues

• sleep deprivation, time zone changes and irregular sleep schedules

• irregular quality, availability and variety of meals

• exposures to extremes of climate and altitude

• limited availability of immediate medical care

• lack of refrigeration or electricity for medications, medical supplies or equipment

• increased physical demands related to prolonged standing, walking, or exertion

• routine use of personal protective equipment such as respirators and protective clothing

• possible exposure to infectious organisms, chemical or radiologic agents

• risk related to allergy, adverse events or side effects from medications, vaccines or other required pharmaceutical interventions

• for pregnant women, possible risk to a developing fetus

I have read the above medical questionnaire and statements. I have answered all questions accurately and to the best of my knowledge. I realize that further information or testing may be needed from my private physician or other sources to clarify my fitness for this duty. I know of no condition which would impair my ability to function fully on a CDC emergency response team now or for the following two years.

Signature________________________________ Date______________________

You may STOP here.

The clinic staff and physician will complete the remainder of this form

Name:____________________________________ Date:_____________

TO BE COMPLETED BY PHYSICIAN:

Height_____

Weight_____

Pulse_____

BP________

Distant vision:

R 20/___ L 20/___ Corrected? Y N

CLINICAL EVALUATION

Check each item as indicated. Enter ‘NE’ if not evaluated

Normal

Abnormal

Notes or Other Comments

1. Skin

2. Head and neck (thyroid)

3. Ear, nose and throat

4. Lymph nodes

5. Eyes (include fundoscopic)

6. Lungs

7. Breast

8. Heart

9. Abdomen

10. Genitalia (if indicated)

11. Rectal exam (if indicated)

12. Vascular system

13. Extremities and spine

14. Neurological

15. Psychiatric (specify any significant cognitive, mood or behavioral observations)

SUMMARY OF PHYSICIAN FINDINGS ON HISTORY AND EXAM

RECOMMENDATIONS FOR FURTHER EVALUATION

CLEARED __ NOT CLEARED __

(attach additional page if necessary)

PHYSICIAN NAME & ADDRESS

PHYSICIAN PHONE:

FAX:

E-MAIL ADDRESS:

PHYSICIAN SIGNATURE

DATE