DD_2766.pdf

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Medical Surviellance Examination Services
Solicitation number
FA6703-13-T-0007
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Answer to Question 4 AF2766.

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Attachment 21c DD2766 Adult Prevention and Chronic Care Flowsheet.pdf Revision not stated Occupational Health Services

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Attachment_1 _PWS _6_May_2013.pdf PDF
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Q A.pdf PDF
SF_88 1 .pdf PDF
sf78_-_Certificate_of_Medical_Exam.pdf PDF
AF1753.pdf PDF
Attachment_1 _PWS _25_Apr_2013.pdf PDF
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WD_2005-2133.pdf PDF
Attachemnt_3 _Medical_Examination_Price_List.pdf PDF
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ADULT PREVENTION AND CHRONIC CARE FLOWSHEET

(This form is subject to the Privacy Act of 1974 – Use DD form 2005)

1. ALLERGIES

a. MEDICATION ALLERGIES b. OTHER ALLERGIES

2. CHRONIC ILLNESS 3. MEDICATIONS

4. HOSPITALIZATIONS/SURGERIES

5. COUNSELING

F FITNESS a. DATE D DENTAL b. AGE

I INJURY PREVENTION

N NUTRITION/FOLATE

C CANCER PREVENTION

c. TOPIC

S SAFE SEX d. DATE FP FAMILY PLANNING e. AGE

RX PRESENT MEDICATIONS

MH MENTAL HEALTH/STRESS/SUICIDE/

OCCUPATIONAL STRESS

f. TOPIC

H HORMONE/CALCIUM REPLACEMENT g. DATE To TOBACCO h. AGE

A ALCOHOL/SUBSTANCE ABUSE

t TRAVEL o OCCUPATIONAL EXPOSURE

(HEARING THRESHOLD CHANGES/

CUMULATIVE TRAUMA DISORDER)

i. TOPIC

j. DATE

k. AGE

l. TOPIC

ADVANCE DIRECTIVES: DATE FILED

PATIENT’S IDENTIFICATION (Use this space for mechanical imprint)

SUPPLIED (Navy) 2766-0102-LF-984-8400, pkg-100

RECORDS MAINTAINED AT:

PATIENT’S NAME

LAST FIRST M.I.

SEX

RELATIONSHIP TO SPONSOR STATUS RANK/GRADE

SPONSOR’S NAME (Last, First, Middle Initial) DEPT/SERVICE

ORGANIZATION SSN/ID NUMBER DATE OF BIRTH

DD FORM 2766, (Rev. 01-00) PAGE 1 of 4 PAGES

6. FAMILY HISTORY M = Mother, F = Father, S = Sibling, MGM = Maternal Grandmother, MGF – Maternal Grandfather, PGM = Paternal Grandmother, PGF = Paternal Grandfather)

a. CANCER (Specify)

b. CARDIOVASCULAR DISEASE (Specify)

c. DIABETES (Specify)

d. MENTAL ILLNESS/CHEMICAL DEPENDENCY (Specify)

7. SCREENING EXAMS (* = Actual Result, ** = Tricare Benefit, N = Normal, X = Abnormal, E = Done Elsewhere, R = Refused, NA = Not Indicated) (● = Next Due)

c. YEAR a. TEST b. FREQUENCY

d. AGE

e. DATES (1) CLINICAL DISEASE

PREV EVAL/PHA (HEAR)

ANNUAL

*(2) WEIGHT ANNUAL FOR ACTIVE DUTY

*(3) HEIGHT ANNUAL FOR ACTIVE DUTY

*(4) BLOOD PRESSURE ONCE q 2 YRS FOR BP <

130/85, ANNUAL IF GREATER

*(5) CHOLESTEROL** *q 5 YRS FOR AGE > 18 q YR IF PREV ABN

(6) HEARING CLINICAL DISCRETION

(7) SKIN EXAM (Cancer) ANNUAL IF AT RISK

(8) ORAL/DENTAL ** ANNUAL

(9) EYE/VISION**

ROUTINE ACUITY WITH PERIODIC

ASSESSMENT DIABETES ANNUAL

GLAUCOMA CHECK:

Blacks q 3-5 yrs age 20-29 All q 2-4 years age 40-64

(10) BREAST EXAM ANNUAL: > 40 YRS

(11) MAMMOGRAM** BASELINE @ 40, q 2 YRS

40-50, ANNUALLY > 50

(12) PAP

**(Digital Rectal Exam)

BASELINE: AGE 18 OR ONSET OF

SEXUAL ACTIVITY

AFTER 3 NL ANNUAL EXAMS,

PERFORM q 1-3 years.

(13) FECAL OCCULT

BLOOD

ANNUAL > 50 yrs

(14) SIGMOID EVERY 3-5 YRS: > 50 YRS

(15) COLONOSCOPY HIGH RISK q 5 YRS > 40 YRS

(16) TESTICULAR HIGH RISK ANNUAL 13-39 YRS

(17) PROSTATE**

**(DIGITAL RECTAL EXAM)

WITH P.E. > 40 YRS (Presently recommended annually)

(18) RUBELLA SCREEN

(Females)

ONCE BETWEEN AGES 12-18 YRS

(Unless prev vaccinated)

(19) OCCUPATIONAL

SCREENING EXAMS

APPROPRIATE TO EXPOSURES

(20)

(21)

(22)

DD FORM 2766, (Rev. 01-00) PAGE 2 of 4 PAGES

8. OCCUPATIONAL HISTORY/RISK

a. PRP YES NO

b. FLYING STATUS YES NO

9. IMMUNIZATIONS (Enter numeric class in sub block) (1)

IMMUNIZATION

(2) DATE

(ddmmmyyyy)

a. HEP A #1

b. HEP A #2

c. HEP B #1

d. HEP B #2

(1)

IMMUNIZATION

(2) DATE

(ddmmmyyyy)

f. MMR #1

g. MMR #2 h.

PNEUMOCOCCUS

i. POLIO OPV=O

IPV = I

(1)

IMMUNIZATION

(2) DATE

(ddmmmyyyy)

j. TD (q 10 YRS) (Last)

k. TD (DUE)

l. YELLOW

FEVER (LAST)

m. YELLOW

FEVER

(1)

IMMUNIZATION

(2) DATE

(ddmmmyyyy)

n. TYPHOID (Enter numeric class in sub block) Oral=O, TYPHUM

VI=1, TYPHOID USP = 2

(1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE

o. ANTHRAX

(1) INITIAL DATE (2) 2 WEEK DATE (3) 4 WEEK DATE (4) 6 MONTH DATE (5) 12 MONTH DATE (6) 18 MONTH DATE

p. PPD (Enter mm and date)

(1)(a) mm (2)(a) mm (3)(a) mm (4)(a) mm (5)(a) mm (6)(a) mm (7)(a) mm

(b) DATE (b) DATE (b) DATE (b) DATE (b) DATE (b) DATE (b) DATE

q. INFLUENZA (1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE (7) DATE

r. VARICELLA (1) DATE (2) DATE u. JAPANESE

ENCEPHALITIS

(1) DATE (2) DATE (3) DATE (4) DATE

s. MENINGO (1) DATE (2) DATE v. OTHER (Specify) (1) DATE (2) DATE (3) DATE

t. ADENO (1) DATE (2) DATE w. OTHER (Specify) (1) DATE (2) DATE (3) DATE

10. READINESS (Glucose-6-phosphate dehydrogenase)

a. DNA DATE: b. BLOOD

TYPE

DATE: RESULT: c. G-PD DATE: RESULT: d. SICKLE

CELL

DATE: RESULT:

e. PERMANENT PROFILE CHANGE (1) DATE (2) P: (3) U: (4) L: (5) H: (6) E: (7) S:

f. GLASSES/GAS/MASK Rx:

(1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE

g. DENTAL EXAM (Enter numeric class in sub block)

(1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE

h. HIV TESTING (1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE

i. FITNESS (in sub block enter P=Pass, F=Fail, W=Waiver)

(1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE

(1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE

(1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE

11. PRE/POST DEPLOYMENT HISTORY

a. LOCATION

(1) PREDEPLOYMENT (a) DATE (b) DATE (c) DATE (d) DATE (e) DATE (f) DATE

(2) POSTDEPLOYMENT (a) DATE (b) DATE (c) DATE (d) DATE (e) DATE (f) DATE

b. LOCATION

(1) PREDEPLOYMENT (a) DATE (b) DATE (c) DATE (d) DATE (e) DATE (f) DATE

(2) POSTDEPLOYMENT (a) DATE (b) DATE (c) DATE (d) DATE (e) DATE (f) DATE

c. CHART AUDIT

DD FORM 2766, (Rev. 01-00) PAGE 3 of 4 PAGES

(Continuation Sheet)

a. TEST b. FREQUENCY

DATES

(a) (b) (c) (d) (e) (f)

REMARKS

RECORDS MAINTAINED AT:

PATIENT’S NAME

LAST FIRST M.I.

SEX

RELATIONSHIP TO SPONSOR STATUS RANK/GRADE

SPONSOR’S NAME (Last, First, Middle Initial) DEPT/SERVICE

ORGANIZATION SSN/ID NUMBER DATE OF BIRTH

DD FORM 2766, (Rev. 01-00) PAGE 4 of 4 PAGES

ADULT PREVENTION AND CHRONIC CARE FLOWSHEET
b. OTHER ALLERGIES
ADULT PREVENTION AND CHRONIC CARE FLOWSHEET
8. OCCUPATIONAL HISTORY/RISK
YES
NO
YES

Untitled

other allergies:
chronic illness:
1:
2:
3:
4:
5:
6:
0:
7:
meds:
0:
1:
2:
3:
4:
5:
6:
7:
surgeries:
0:
1:
2:
3:
surgeries cont'd:
0:
1:
2:
3:
Fitness:
0:
1:
2:
3:
4:
11:
12:
13:
14:
20:
22:
23:
24:
21:
age:
0:
1:
2:
3:
4:
9:
11:
12:
13:
14:
20:
21:
22:
23:
24:
topic c:
med allergies:
Year:
1:
2:
3:
4:
5:
0:
Age:
0:
1:
2:
3:
4:
5:
lname:
fname:
MI:
sex:
Relationship:
stat:
rank:
Sponsor name:
dept:
org:
ssn:
dob:
Test:
0:
1:
3:
5:
6:
8:
9:
11:
13:
14:
16:
18:
19:
21:
22:
24:
26:
27:
freq:
0:
1:
3:
5:
6:
8:
9:
11:
13:
14:
16:
18:
19:
21:
22:
24:
26:
27:
test date:
0:
1:
3:
5:
6:
8:
9:
11:
13:
14:
16:
18:
19:
21:
22:
24:
26:
27:
test date b:
0:
1:
3:
5:
6:
8:
9:
11:
13:
14:
16:
18:
19:
21:
22:
24:
26:
27:
test date c:
0:
1:
3:
5:
6:
8:
9:
11:
13:
14:
16:
18:
19:
21:
22:
24:
26:
27:
test date d:
0:
1:
3:
5:
6:
8:
9:
11:
13:
14:
16:
18:
19:
21:
22:
24:
26:
27:
test date e:
0:
1:
3:
5:
6:
8:
9:
11:
13:
14:
16:
18:
19:
21:
22:
24:
26:
27:
test date f:
0:
1:
3:
5:
6:
8:
9:
11:
13:
14:
16:
18:
19:
21:
22:
24:
26:
27:
records:
reset:
clinical date2:
clinical date3:
clinical date4:
clinical date5:
clinical date6:
PRP No: Off
PRP YES: Off
Flying YES: Off
Flying No: Off
hepa #2:
hepb #1:
hepb #2:
hepa #1:
td:
td due:
yf:
yf date:
mmrs#1:
mmrs#2:
pneu:
polio:
immun a:
immunb:
immunc:
immund:
immun a name:
immunb name:
immund name:
immune cname:
typhoid3:
typhoid4:
typhoid5:
typhoid6:
typ sub block:
3:
6:
9:
12:
14:
0:
anthrax 2:
anthrax 3:
anthrax12:
anthrax 18:
anthrax4:
PPD:
0:
1:
2:
4:
5:
6:
8:
ppd date:
ppd date2:
ppd date 3:
PPD date 4:
ppd date5:
ppd date 6:
ppd date 7:
anthrax initial:
influenza:
0:
1:
2:
3:
4:
5:
6:
varicella:
0:
1:
3:
4:
5:
6:
meningo:
0:
1:
2:
4:
5:
6:
adeno:
1:
2:
4:
5:
6:
0:
DNA:
dna date:
blood:
blood date:
blood res:
g-pd:
g-pd date:
G-PD res:
sickle:
sickle cell date:
sickle result:
typhoid2:
typhoid1:
f:
0:
1:
2:
3:
4:
5:
g:
0:
1:
2:
3:
4:
5:
h:
0:
1:
2:
3:
4:
5:
i:
0:
1:
2:
3:
4:
5:
i cont:
0:
1:
2:
3:
4:
5:
i line 3:
0:
1:
2:
3:
4:
5:
Predeployment:
0:
1:
2:
3:
4:
5:
post:
0:
1:
2:
3:
4:
5:
predeployment contd:
0:
1:
2:
3:
4:
5:
post contd:
0:
1:
2:
3:
4:
5:
audit:
0:
1:
2:
3:
4:
5:
ppc:
2:
3:
4:
5:
12:
1:
Fitness sub:
4:
7:
10:
13:
16:
0:
dental sub:
0:
2:
4:
6:
8:
10:
rem:
clinical date:
0:
weight:
0:
1:
2:
3:
4:
5:
Height:
0:
1:
2:
3:
4:
5:
bp:
0:
1:
2:
3:
4:
5:
chol:
0:
1:
2:
3:
4:
5:
hearing:
0:
1:
2:
3:
4:
5:
skin:
0:
1:
2:
3:
4:
5:
oral:
0:
1:
2:
3:
4:
5:
eye:
0:
1:
2:
3:
4:
5:
mam:
0:
1:
2:
3:
4:
5:
pap:
0:
1:
2:
3:
4:
5:
fecal:
0:
1:
2:
3:
4:
5:
sigmoid:
0:
1:
2:
3:
4:
5:
colon:
0:
1:
3:
4:
5:
2:
testicular:
0:
1:
2:
3:
4:
5:
prostate:
0:
1:
2:
3:
4:
5:
rubella:
0:
1:
2:
3:
4:
5:
occ:
0:
1:
2:
3:
4:
5:
date 20:
0:
1:
2:
3:
4:
5:
date 21:
0:
1:
2:
3:
4:
5:
date 22:
0:
1:
2:
3:
4:
5:
breast:
0:
1:
2:
3:
4:
5:
PPC:
cancer:
card:
diabetes:
mental illness:
safe sex:
safe sex 2:
safe sex 3:
fp age:
2:
1:
0:
safe sex4:
fpage:
3:
4:
safe sex 5:
topic 2:
hormone:
topic 3:
topic 4:

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