Wake_Island_Medical_Questionnaire_V11_(1).pdf

Wake Island Medical Questionnaire Phone 808-424-2405 Fax: 808-424-2177 or email doctor@ wakeisland.net

Wake Island Medical Questionnaire V11 Dated July, 2017

Instructions: Please carefully read and answer ALL items. Sign, date and initial ALL fields, as indicated, on the form. Incomplete forms cannot be processed and will be returned for resubmission.

Today’s Date Expected Arrival on Wake Expected Departure Wake

Identification and Contact Information Last name, First name Middle initial

Current address

City State Zip Country

Phone Number Email Address

Sponsoring Organization

O ccupation (W hile on W ake Island) Have you been on Wake previously?

Yes ☐ No ☐

Next of K in Next of K in Phone Num ber

Medical Information Incomplete medical information will delay your medical clearance required for entry onto Wake island

Age Date of B irth (day, m onth, and year) Sex

Current physician Physician phone number

Height Weight Date of last physical

Blood pressure measurement Date of b lood pressure m easurem ent W here did you have your b lood 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 M edications

W hat prescription m edications are you currently taking?

P lease provide the nam e and dose for each m edication, or enter None

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

Non- Prescription and Herbal Medications

Have you ever had any of the below medical conditions?

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

1) Date of m ost recent sym ptom s for each “YES” response..

2) Date of m ost recent treatm ent by a m edical professional for each “YES” response.

3) Specia l treatm ents and m edications prescribed for each “YES” response.

Surgical and Procedure H istory 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 perform ed

Asthma YES ☐ NO ☐ CO PD or other lung disease YES ☐ NO ☐ Sleep apnea YES ☐ NO ☐ Do you use a CPAP device YES ☐ NO ☐

Tuberculosis (aka. TB) YES ☐ NO ☐ Shortness of Breath YES ☐ NO ☐ Coughing up blood YES ☐ NO ☐ Chest pain YES ☐ NO ☐ Heart attack or S tent P lacem ent

YES ☐ NO ☐

Irregular Heartbeat YES ☐ NO ☐ Palpitations YES ☐ NO ☐ Pacemaker YES ☐ NO ☐ Swelling in legs or feet YES ☐ NO ☐ Varicose veins YES ☐ NO ☐ Blood clot in legs or lungs YES ☐ NO ☐ High Blood Pressure YES ☐ NO ☐ Congestive Heart Failure YES ☐ NO ☐ Fainting YES ☐ NO ☐ Dizziness YES ☐ NO ☐ Anemia YES ☐ NO ☐ Diabetes YES ☐ NO ☐ Thyroid disease YES ☐ NO ☐ Liver disease YES ☐ NO ☐ Hepatitis A, Hepatitis B, or C YES ☐ NO ☐ Kidney disease YES ☐ NO ☐ Cancer YES ☐ NO ☐ Bleeding disorders YES ☐ NO ☐ Irritable bowel d isease YES ☐ NO ☐ Recurrent diarrhea YES ☐ NO ☐ Blood in stool YES ☐ NO ☐ Organ transplant YES ☐ NO ☐

Vom iting blood YES ☐ NO ☐ Motion sickness YES ☐ NO ☐ Tropical disease, & parasites YES ☐ NO ☐ Seizures or convulsions YES ☐ NO ☐ Traumatic Brain Injury YES ☐ NO ☐ Decompression sickness YES ☐ NO ☐ Do you use crutches, braces or any medical device?

YES ☐ NO ☐

Do you have a disability that requires specia l equipm ent or living conditions?

YES ☐ NO ☐

Do you have any dietary restrictions?

YES ☐ NO ☐

Auto immune disease? YES ☐ NO ☐ Recurrent headaches? YES ☐ NO ☐ Blurred vision? YES ☐ NO ☐ Stroke or Transient Ischemic Attack (TIA)?

YES ☐ NO ☐

W eakness in any extrem ity? YES ☐ NO ☐ Num bness in any extrem ity? YES ☐ NO ☐ Sexually transmitted disease? YES ☐ NO ☐ Psychiatric conditions such as PTSD, depression, bipolar disease, anxiety, attention deficit disorder or anger management issues?

YES ☐ NO ☐

Have you ever been treated for drug or alcohol abuse?

YES ☐ NO ☐

Hospitalization H istory Have you EVER been Hospitalized? List all approximate dates and reason for Hospitalization

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 H istory Do you smoke?

YES ☐ NO☐

How m uch do you sm oke per day? How m any years have you sm oked?

Do you drink a lcohol?

YES ☐ NO☐

How m uch alcohol do you drink?

Do you use recreational drugs?

YES ☐ NO☐

Which drugs? How often do you use these drugs?

Declaration and S ignature

I declare that I have, to the best of m y know ledge, 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 am required to bring sufficient personal medication to cover the entire duration of my stay on Wake. Furthermore, it is my responsibility to have adequate refills for all of m y prescription and over the counter m edications.

I am financia lly liable for any m edical em ergencies or m edical service that I m ay require while resid ing on W ake Island and that Chugach Federal Solutions, Inc. w ill not pay any part of these expenses thereof.

Printed Name: Signature: Date:

Or Electronically below

X Requestors Signature

Hhhhhhh

Authorization for Use and Disclosure of Protected Health Information

Last name, First name, Middle initial

Current address

City State Zip

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 the persons indicated. If you are under the age of 18 your parent or legal guardian may sign on your behalf. RMI may not condition treatment on whether the individual signs this authorization. Note that health information released pursuant to this Consent may be re-disclosed by the recipient. Individual is entitled to a copy of this Consent.

1. ____________________________ _____________________ Name Relationship

2. ____________________________ _____________________ Name Relationship

☐ Medical record from (insert date): to (insert date) ☐ Entire m edical record, including patient h istory, notes, test results, radio logy studies, film s, referra ls, consults, billing and insurance records, records from other health care providers, and information relating to sexually transm itted diseases, A IDS and H lV , and alcohol and drug abuse.

☐ Other:

Information to be withheld: ______________________________________ Purpose for d isclosure: ☐ At request of individual ☐ Other:

Unless earlier revoked, this Consent expires one (1) year from the date stated below.

By signing below, I further understand and agree to the following:

(1) This authorization is voluntary and I do not have to sign it in order to receive treatment or services from RMl. I understand that I have the right to refuse to sign this authorization'

(2) W hen m y inform ation is used or d isclosed pursuant to th is authorization, it m ay be re-disclosed by the recip ient and m ay no longer be protected by state and federal privacy laws, including H IPAA 's Privacy Rule.

(3) | have a right to revoke this authorization by providing written notice to: HIPAA Privacy Officer, Remote Medical international, 4259 23rd Ave. W ., Suite 100, Seattle, W A 98199. However, th is authorization m ay not be revoked if RM I has taken action on this authorization prior to receiving my written revocation notice.

(4) This authorization has been com pleted fu lly and m y questions about th is authorization have been answered.

(5) | have been provided a copy of this authorization.

Printed Name: Signature: Date:

Printed Name of Legal Representative (if applicable):

Legal Representative Signature and Date: __