Attach_2_CDC_Responder_Readiness_Program_Interim_Med_Eval.pdf

CDC Responder Readiness Program Interim Medical Evaluation

Name: ________________________________________ Date: ____________

User ID: _____________________________________

Instructions: Please answer each of the following questions with particular emphasis on the period of time since your last deployment medical evaluation was performed. Provide explanations for any positive response in the space provided at the bottom of this page. The information you provide in this medical update is private and confidential and will be reviewed only by medical personnel. A complete history and physical exam may be recommended if there has been a significant change in your health status since your last evaluation.

YES NO

[ ] [ ] 1. Have you seen a health care provider for any new medical concern(s) during the past year?

[ ] [ ] 2.Have you been advised to seek treatment for a medical symptoms or condition since your last deployment evaluation?

[ ] [ ] 3. Are you being evaluated on a regular basis for any chronic or recurrent medical condition(s)?

[ ] [ ] 4. Have you been hospitalized since your last deployment evaluation?

[ ] [ ] 5. Have you had any surgical procedures since your last deployment evaluation?

[ ] [ ] 6. Have you been treated by (or been recommended to receive treatment from) a health care provider for any mental health condition?

[ ] [ ] 7. Do you have any physical or emotional complaints, symptoms or concerns that you feel should be evaluated at this time?

[ ] [ ] 8. Do you take medication? If so, list all medications and the reason for taking in the space below.

Please use the space below to comment fully on any questions that received a positive (YES) response above. You may also provide any additional information you wish to be considered when your medical clearance evaluation is made.

Signature:____________________________________ _____ Date:_______________

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 physician.

Deployment on a CDC 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 days 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

• Lifting and moving containers, equipment and boxes

• Insect bites/stings

• Loud noises (machinery and aircraft)

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 in the capacity of a CDC Deployment Team member now or for the following year.

Signature:__________________________________________ Date:______________

You may STOP here.

The clinic staff will complete the remainder of this form

Name:_____________________________________________ Date:_______________

TO BE COMPLETED BY CLINICAL STAFF:

CLINICAL EVALUATION:

ASSESSMENT:

PLAN:

CDC Deployment Interim Medical Evaluation Statement

I have reviewed the interim medical history of_________________________

(User ID: ________________________)

Based upon this patient’s medical history, it is my opinion that:

Yes No

This individual appears mentally and physically capable of deployment.

Based on review of the interim medical history, this individual requires a full medical examination, including history, physical, lab work, and other diagnostic tests before deployment

Name of Medical Provider (print): ___________________________

Signature: ____________________

Date: ____________________