Attachment_4_FY18_Wake_Island_Medical_Questionnaire_V14_PDF.pdf

Wake Island Medical Questionnaire

Phone: 808-424-2405 Fax: 808-424-2177 email: wakedoctor@remotemedical.com

Wake Island Medical Questionnaire V14 AK/LC 20 July 2018

General Information

Wake Island is a very remote location in the Pacific Ocean 2300+ miles from civilization. The Wake Island

Medical Clinic is an urgent/emergent remote clinic with limited diagnostic and treatment capabilities.

We are staffed with one Physician and one Paramedic. We have no dentist, no x-ray, no lab, no blood products, no CT/MRI and no ultrasound. If we have to evacuate someone in a medical emergency it can take 36-72 hours to reach definitive care. For these reasons medical clearance is needed to reduce risks to your life and potential contagious disease.

Medical Clearance

Please answer ALL questions in the questionnaire and send at least 30 days (if possible) prior to arrival. Everything is applicable - Incomplete forms will be returned thus delaying clearance process.

Labs: CBC Immunizations**: Measles

CMP (or proof of immunity) Rubella

Hemoglobin A1C (HbA1C) Varicella

Lipid Profile Tetanus

Hepatitis B (HBsAg) Influenza (October-March)

Hepatitis C (anti-HCV)

PPD or Tine test for TB

Urine analysis (UA)

Ova and Parasites (for kitchen staff only)

Recommend: Typhoid, Hepatitis A and Hepatitis B vaccinations (required for kitchen staff)

Please have your Primary Care Provider sign page 3 of the Questionnaire.

We look forward to you completing this process and visiting our beautiful Island! Please feel free to contact us with any questions. Phone: 808-424-2405 email: wakedoctor@remotemedical.com

**If you are not sure about your immunizations (whether you have had them or not), you can have titers drawn to check immunity levels.

Length of Stay Questionnaire Physical Exam Lab work EKG

Less than 1 week Yes within 1 year of arrival

More than 1 week Yes within 6 months of arrival Within 6 months of arrival >45 years old

Reoccurring stays or longer than 1 year

Yes Annually annually >45 years old annually mailto:wakedoctor@remotemedical.com

Wake Island Medical Questionnaire V14 AK/LC 20 July 2018

Instructions: Please carefully read and answer ALL items.

Incomplete forms cannot be processed and will be returned for resubmission.

Today’s Date Expected Arrival on Wake Expected Departure from Wake

Identification and Contact Information

Last name, First name, Middle initial

Current address

City State Zip Country

Phone Number Email Address

Sponsoring Organization and email/phone number for sponsoring POC (point of contact)

Occupation (While on Wake Island) Have you been on Wake previously?

Yes ☐ No ☐ If yes, when _____________

Next of Kin Next of Kin Phone Number

Medical Information Age Date of Birth (day, month, and year) Sex

Current physician Physician phone number

Height Weight Date of last physical

Blood pressure measurement

Date of blood pressure measurement Where did you have your blood pressure taken?

Allergies: List or enter none

Medications:* Food allergies: Insect stings: Iodine, eggs, or contrast dye

*List the specific medications you are allergic to and the type or reaction you have to the medication

Prescription Medications

What prescription medications are you currently taking? Please provide the name and dose for each medication, or enter None

Are you taking your medications as prescribed by your healthcare provider? Yes ☐ No ☐

Non- Prescription and Herbal Medications

Wake Island Medical Questionnaire V14 AK/LC 20 July 2018

Have you ever had any of the below medical conditions?

Provide the following information for each “YES” response or enter N/A

1) Date of most recent symptoms for each “YES” response.

2) Date of most recent treatment by a medical professional for each “YES” response.

3) Special treatments and medications prescribed for each “YES” response.

Surgical and Procedure History

Please list all operations you have had and the approximate dates of the operation.

Type of Surgery or Procedure(s) (example: .Appendix removal, Cardiac stent placement, etc…) Date performed

Have you EVER been Hospitalized? Please list approximate dates.

Reason for hospitalization (Inpatient or outpatient) Date Hospitalized

Dental (Wake Island has no Dentist)

Do you have any dental issues that require attention? Yes ☐ No ☐

If YES please explain. When was your last dental checkup?

Social History

Do you smoke?

YES ☐ NO☐

How much do you smoke per day?

How many years have you smoked?

Do you drink alcohol?

YES ☐ NO☐

How much alcohol do you drink per week?

Do you use recreational drugs?

YES ☐ NO☐

Which drugs? How often do you use these drugs?

Primary Care Provider (e.g. MD, PA, NP)

I have examined the applicant and verify they are fit for duty.

I understand the applicant will be traveling to and working on a remote Island with limited medical facilities.

Printed Name: Date: __________________

Signature: _________________________________

Or Electronically below

X

Consent for Treatment

I agree and consent to participate in the medical services offered and provided by Remote Medical International professionals while on Wake Island.

I understand that I am consenting and agreeing only to those services that the provider is qualified to provide within: (1) the scope of the provider’s license, certification, and training; or (2) the scope of license, certification, and training of the remote medical providers directly supervising physician(s).

This consent remains valid until I permanently leave Wake Island or sign a Refusal of Care.

Consent to Release Medical Information Without the consent of the individual, Remote Medical International (RMI) is prohibited from releasing medical information except to carry out treatment, payment, or healthcare operations. Your signature below authorizes

RMI to release your medical information to your employer and/or your employer’s prime contractor solely as required for operational purposes. RMI may not condition treatment on whether you sign this authorization.

Note that health information released pursuant to this Consent may not be re-disclosed by the recipient.

Individual is entitled to a copy of this Consent.

Declaration and Signature

I have read and agree to above statements regarding Consent for treatment and Consent to release Medical information.

I declare that I have, to the best of my knowledge, reviewed and answered all of the questions accurately.

I understand that I am going to a remote location where medical care is limited.

I understand that I am required to be in good health and need to bring sufficient personal medication (i.e.

prescriptions and over the counter medications) to cover the entire duration of my stay on Wake.

I am financially liable for any medical emergencies or medical service that I may require while residing on

Wake Island and that Chugach Federal Solutions, Inc. will not pay any part of these expenses thereof.

Printed Name: Date: __________________

Signature: _________________________________

Or Electronically below

X