attmt__2_Candidate_Medical_Examination _History _ _Vision_Forms.pdf

Page 1 of 12 Rev. Mar. 5, 2012

CANDIDATE'S NAME (Last, First, Middle Initial) APPLICANT ID#:

VETERANS' PREFERENCE ELIGIBILITY: SEX: DATE OF BIRTH: (mm/dd/yy)

Yes No Male Female

YOUR CURRENT OCCUPATION: YOUR CURRENT EMPLOYER:

HOW LONG IN CURRENT POSITION? (years/months)

CHECK THE OCCUPATION FOR WHICH YOU ARE BEING CONSIDERED:

Border Patrol Agent Marine Interdiction Agent

Customs and Border Protection Officer Other: ____________________

NAME AND ADDRESS OF EXAMINING FACILITY:

PHONE NUMBER: (including area code)

REQUIRED SERVICES: (check when completed and attach reports) Medical History Vision Screening General Physical Examination EKG with interpretation (including waist measurements and fitness questionnaire) TB Skin Test Audiometry 1View Chest Xray, if appropriate per TB form page 13 Repeat Audiometry, if appropriate

AGENCY USE ONLY

DATE OF EXAMINATION:

NAME OF EXAMINING PHYSICIAN:

MEDICAL EXAMINATION AND HISTORY REPORT

CANDIDATES AND EXAMINING FACILITIES: Please DO NOT write in "AGENCY USE ONLY" areas.

CANDIDATES: Complete all portions of this form before reporting for the medical examination. Failure to answer any questions or disclose a known medical condition or failure to place signature where indicated may result in disqualification from employment consideration. Please print or type. Each "yes" answer to a medical history question requires that you provide a brief explanation in the comment section provided. (NOTE: Because this exam may include a fitness test, please dress appropriately.) This examination is being conducted for employment purposes only; it does not substitute for a periodic health examination conducted by your private provider.

ATTENTION VETERANS: The Questionnaire for National Security Positions (SF-86) does not require you to disclose mental health counseling on that form if such counseling was “strictly related to adjustments from service in a military combat environment” (SF-86, Section 21 Mental and Emotional Health). However, all mental health counseling must be disclosed on this Medical Examination and History Report form in order to determine if you meet the minimum medical qualifications for the position.

EXAMINING FACILITIES: (Do NOT bill examinee for exam. CHS is responsible for all payments.) Conduct medical exam and all other required services in accordance with instructions provided by the contracting organization. Complete this form except where indicated. Please print or type.

Rev. Mar. 5, 2012

CANDIDATE'S NAME: APPLICANT ID#: DATE:

1 Have you ever been refused employment or been unable to hold a job or stay in school due to any medical condition? (If yes, specify date, where and give details.) Yes No

2 Have you ever been treated for a mental condition? ( If yes, specify date, where, and give details.)

Yes No

3 Have you had, or have you been advised to have, any operation? ( If yes, describe and give date, details of problem and name of procedure.) Yes No

4 Have you ever been a patient in any type of hospital? (If yes, specify date, where, why.)

Yes No

5 Have you consulted or been treated by clinics, physicians, healers, or other practitioners other than for minor illness? ( If yes, give date and complete details.) Yes No

6 Have you ever been rejected for or separated from military service because of physical, mental, or other medical reasons? (If yes, give date, reason, and type of discharge, whether honorable or other than honorable, for unfitness or unsuitability.) Yes No

7 Have you ever received, is there pending, or have you applied for pension or compensation for existing disability? (If yes, specify what kind, granted by whom, and what amount, when, why and attach most recent disability rating decision.) Yes No

8 Are you: Left handed OR Right handed

9 Year of last Tetanus booster:_____ I don't know the year of my last Tetanus booster

10 MEDICATIONS: (List prescription and non-prescription medications, dosage, No Meds and reason for taking.)

Medication Dosage/frequency Reason Currently taking Taken in the last year

11 ALLERGIES/REACTIONS: (List substances to which you are allergic or to which you have reactions and any medications taken for their treatment.)

MEDICAL HISTORY

Check "yes" or "no" for each item. For each "yes," you must provide an explanation in the space below. Explanations to "yes" answers must include Date, Where, How and any Follow-up Testing/Treatment.

Page 3 of 12 Rev. Mar. 5, 2012

CANDIDATE'S NAME: APPLICANT ID#:

Have you experienced any of the following? ( Explain "yes" responses in the space below or at the bottom of the page.)

12 Yes No Treatment:__diet __pills __insulin 13 Yes No 14 Yes No 15 Yes No 16 Yes No 17 Yes No 18 Yes No 19 Yes No 20 Yes No 21 Yes No 22 Yes No 23 Yes No 24 Yes No 25 Yes No 26 Yes No 27 Yes No 28 Yes No 29 Yes No Date of last episode:

30 Yes No

Yes No 31 Yes No 32 Yes No 33 Yes No 34 Yes No Date of last episode:

35 Yes No 36 Yes No 37 Yes No 38 Yes No 39 Yes No 40 Yes No 41 Yes No 42 Yes No 43 Yes No 44 Yes No If viral, specify A, B or C:

45 Yes No If yes, indicate number of shots:

46 Yes No 47 Yes No If yes, year repaired:

48 Yes No 49 Yes No 50 Yes No 51 Yes No 52 Yes No 53 Yes No 54 Yes No 55 Yes No 56 Heat stroke……………………………………………...…….…… Yes No 57 Frost bite………………………………………………...………… Yes No

CANDIDATE'S COMMENTS

(For all "yes" answers above, you must include date, where (body part affected), how and any follow-up testing and/or treatments.)

Question Number Date of Onset Details

DATE:

GENERAL

MEDICAL HISTORY

Fainting/syncope (blacking out)………...………………………

Limb or finger amputation/loss…………..………………..…..

Loss of strength or muscle weakness……..………………… Loss of joint/limb movement……………..…..………………..

Trouble walking…………………………...…………………….

Trouble using hip/knee/shoulder………..…………..………… Joint pain, swelling, or injury………..………………..………..

Migraine headaches……………………...…………………

Loss of sensation………………………...….……………………

Arthritis…………....………………………….…………………… Gout……………….…..…………………….……………………….

Skin problems and/or Urticaria………...….…………………… Urinary pain/infection/bleeding…….….…….…………………

Able to work during a migraine?

If yes, how often?______

Hernia…………………………………………….………………...

***Note to Examining Physician: All "yes" responses require detailed comments by candidate and examining physician.

Examining physician comments should be recorded on page 7.***

Kidney disease or kidney stones………...…….………………

Localized weakness/numbness………...……………………..

Tingling in head/hands/legs……………..….….……………….

Lack of coordination……………………….……………………...

Blood in stool…………………………………...…………….…..

Liver disease…………………………………..……………….…

Epilepsy (seizures)……………………...….…………………….

Tremors/shakiness……………………...……………………….

Persistent stomach/abdominal pain………...………………… Stomach ulcers…………………………………..………………..

Vomiting blood……………………….………...………………… Persistent diarrhea/constipation……………...….……………..

Hepatitis………………………………………...…………………

Gall bladder problems………………………...………………

Psychiatric/psychological consultations…………..…………

Received the Hepatitis B vaccine……………….……………….

Episodes of depression…………………………...…………..…

Suicide attempts or plans……………………….………………..

Organ transplant (e.g. kidney, etc.)……………….……………

Back surgery………....…………………………………………..

Are you pregnant?…………………………………...……………

Periods of anxiety……………...…………………...…………..…

Treatment for alcoholism or addiction…………..…………..… Sleep disorders (sleep apnea)….………………….………….

Diabetes……..………………………………..…………..……...

Thyroid disease…..….………………………..…....……....…… Pituitary gland problem…...……...……………………..……… Blood disorder……..…………………...………………..……… Anemia………….……………………………..…………….…….

Back pain or injury………….....……………………..…………..

Page 4 of 12 Rev. Mar. 5, 2012

CANDIDATE'S NAME: APPLICANT ID#: DATE:

Have you had or are you currently experiencing any of the Have you experienced any of the following?

following: (Explain "yes" in space below) (Answer each question; explain "yes" response 58 Blurred vision Yes No in the space below.)

59 Color vision problems Yes No 67 Difficulty hearing Yes No 60 Diagnosis of night vision deficiency Yes No 68 Ringing or buzzing in ears Yes No 61 Diagnosis of glaucoma Yes No 69 Dizziness or balance problem Yes No 62 Diagnosis of cataracts Yes No 70 Chronic ear pain/infection Yes No 63 Diagnosis of any eye disease Yes No 71 Eardrum perforation Yes No 64 Do you wear glasses? Yes No 72 Ear surgery Yes No 65 Do you wear contact lenses? Yes No 73 Loud, constant noise or music 66 Have you ever had eye surgery within the past 15 hours Yes No

(e.g., RK, PRK, LASIK, cataracts, Yes No 74 Loud, sudden noise in past detached retina)? 15 hours Yes No (If yes, specify surgery and date below) 75 Are you in a hearing conservation program? Yes No 76 Do you use hearing protective equipment? Yes No

77 Do you wear a hearing aid? Yes No If yes, specify ___right ___left ___both

78 Chest Pains Yes No 90 Cold hands or feet when others 79 Swelling of ankles or feet Yes No are comfortable in the same room Yes No 80 Leg pains Yes No 91 Numbness of hands or feet Yes No 81 Mitral valve prolapse Yes No 92 Phlebitis or blood clots Yes No 82 Heart murmur Yes No 93 Problems with breathing, 83 History or diagnosis of heart disease Yes No wheezing, or persistent cough Yes No 84 Coronary bypass surgery/other heart 94 History of bronchitis Yes No surgery Yes No 95 Yes No 85 Heart palpitations (rapid or skipped If yes, answer a, b, and c below:

heart beat) Yes No 86 Heart attack or stroke Yes No 87 Abnormal electrocardiogram (EKG) Yes No c. Inhaler use before certain activities? Yes No 88 Abnormal stress test (treadmill) Yes No 96 Shortness of breath Yes No 89 History of high blood pressure Yes No 97 Exposure to tuberculosis Yes No

98 Previous positive TB skin test Yes No

Question Number Date of Onset Details

CANDIDATE'S COMMENTS

For all "yes" answers above, you must include date and any follow-up testing and/or treatments.

***Note to Examining Physician: All "yes" responses require detailed comments by candidate and examining physician. Examining physician comments should be recorded on page 7.***

a. Date of last ER visit or hospitalization:_______

CARDIO-PULMONARY

PLEASE GO TO PAGE 11 NOW AND COMPLETE THE

"CANDIDATE CORRECTIVE LENS INFORMATION"

SECTION

VISION EXAMINATION IS PERFORMED AT THE VISION

CENTER INDICATED IN YOUR INSTRUCTIONS.

MEDICAL HISTORY

VISION AUDIO

b. How often is inhaler used? ____ times yearly

History of asthma

Page 5 of 12 Rev. Mar. 5, 2012

99 Have you ever had or are you currently being treated for any illness or injury other than those noted on pages 2 - 4?) (If yes, specify date, where, and give details.) Yes No

100 Have you ever smoked? Yes No If yes, when? current Type: cigarettes pipe cigar

Number per day:

For how many years:

101 What is your average alcohol consumption in a week? ________ drinks per week (1 drink = 12 oz. Beer, 1 glass Wine, 1.5 oz. Liquor)

CANDIDATE'S SIGNATURE: DATE:

WITNESS' SIGNATURE: DATE:

102 When do you drink alcohol? Weekdays Weekends Both I don't drink alcohol.

Candidate MUST sign below in the presence of a witness from the examining facility.

MEDICAL HISTORY

I certify that I have reviewed the foregoing information supplied by me and that it is complete and correct to the best of my knowledge. I authorize any of the doctors, hospitals or clinics mentioned on these pages to furnish my complete medical record to the Federal Agency (and its authorized Medical Review Officer) for purposes of determining if I am medically qualified for the position for which I have applied.

OTHER MEDICAL CONSIDERATIONS

past -- number of years since quitting

Page 6 of 12 Rev. Mar. 5, 2012

Are you familiar with the physical requirements of the position for which you applied?

Yes No

How many times per week have you been running?

What distance do you run each time? miles (use fractions, if appropriate) How many minutes do you usually run without stopping?

Describe your current physical activity or exercise program:

Intensity: Low Moderate High Frequency: Days per week Duration: Minutes per session Types of Activities:

Are you capable of performing the following:

Yes No Yes No Yes No Yes No Yes No Yes No Yes No

If you have a lifting restriction, what is the maximum number of pounds you are allowed to lift?

_______ lbs Reason: _______________________________________________________________

Place a check next to the response that best describes how often you lift and/or carry objects for each weight category:

Weight (lbs)

10-25 lbs 26-49 lbs 50-69 lbs

70 lbs

How often do you participate in each of the following activities?

Activity Climb Stairs (13-16 steps) Stoop/Bend

Kneel

Candidate's Comments: If you do not know your capabilities, discuss below:

Kneel for 2-3 minutes at a time repeatedly……………………………………………...…

___ Never or Rarely

FITNESS QUESTIONNAIRE

BEFORE answering the following, please read the Practical Exercise Performance Requirements (PEPR) you received from the Minneapolis Hiring Center which was included in the Employment Information booklet. If there are ANY physical tasks or training exercises on the PEPRs that you currently CANNOT perform, list them below.

times per week minutes

Over the last six weeks, on average:

Vigorous aerobic activity at least 3 hrs/week (e.g., cycling, swimming, etc.)………..…

___ Frequently

Do you have any lifting restrictions?

___ Occasionally ___ Occasionally ___ Occasionally

Occasionally (Once every 2 months)

1 1/2 mile timed run…………………………………………………………………………… 1/4 mile run…………………………………………………………………………………… Quickly get in/out of mid-sized car with ease……………………………………………..

Never or Rarely (less than 2/year)

Frequently (1/week or more)

Squat or kneel for up to 45 seconds repeatedly……………………..…………...………

___ Never or Rarely ___ Never or Rarely ___ Never or Rarely

Never or Rarely (less than 2/year)

Occasionally (Once every 2 months)

Frequently (1/week or more)

___ Occasionally ___ Frequently ___Frequently ___Frequently

___ Never or Rarely ___ Occasionally ___ Frequently

___ Never or Rarely ___ Occasionally ___ Frequently ___ Never or Rarely ___ Occasionally ___Frequently

Page 7 of 12 Rev. Mar. 5, 2012

GENERAL INSTRUCTIONS:

For all applicable conditions, the examining physician must comment on the following:

1 Name, date, and result of surgeries or medical tests performed, as well as emergency or urgent care during the past year.

2 Medications used and relief provided.

3 Whether or not the candidate t is experiencing any current or recent problems as a result of the medical condition and whether there are any limitations. If yes, describe in detail. If not, state activities the candidate can perform which demonstrate capabilities.

4 For diabetics, number of hypoglycemic episodes during the past year, chronic or significant complications which may pose a hazard to the candidate or others, degree of diabetic control, and basis for this conclusion.

5 Include with examination results any relevant documents shown to you by the candidate, such as military disability evaluations or medical reports.

EXAMPLES:

1 Candidate writes "knee surgery, 1988" in response to Question #3.

Examining Physician's Comment:

Acceptable: "#3 - ACL repair knee for pain and swelling from a football injury. Now notes mild discomfort in knee in rainy weather; otherwise, able to race-walk 25 miles per week and has no limitations."

Not Acceptable: "OK now" or "WNL."

2 Candidate checks "yes" in response to Question #30 about migraine headaches.

Examining Physician's Comments:

Acceptable: "#30 - Mild headache approximately every three months for the past 10 years. Never had a medical evaluation for this. Uses OTC NSAIDs with relief."

Not Acceptable: "Occasional migraine."

DETAILED COMMENTS:

Typed or Printed Name of Reviewed and SIGNATURE OF EXAMINING PHYSICIAN: DATE:

Examining Physician: discussed medical history with the candidate:

Yes No

EXAMINING PHYSICIAN'S COMMENTS

All "yes" responses in the Medical History require detailed comments by the examining physician.

Examinations are not complete without this detailed information. Please comment in the space provided below. If more space is needed, supply progress notes.

ITEM #

MD or DO MUST sign in indicated spaces.

No PA, NP, LPN, RN, or other signatures accepted -- MD or DO ONLY

Page 8 of 12 Rev. Mar. 5, 2012

Waist

Physician's Comments:

Was repeat Audio required/performed? Yes No Yes No

Frequency: 500 Hz 1000 Hz 2000 Hz 4000 Hz 6000 Hz Right Ear Left Ear

Normal Abnormal Normal Abnormal

Physician's Comments:

Physician's Comments (explain abnormalities or contraindications in space below):

(If yes, attach ALL reports, clearly indicating Initial vs. Repeat. Indicate BEST results on the grid below:

Blood Pressure

Tympanic Membrance Canal/External Ear

3000 Hz

Right Ear Left Ear

Daily Calibration Method: Oscar (machine) Biological (person) Yearly Calibration Date:

Readings

Tested with Hearing Aid?

AUDIOLOGY (Indicate best results and attach all reports.)

If an audio exceeds 30 @ 500-2000 OR 40 @ 3000, repeat 15 hrs. after quiet time.

Measure AGAINST THE SKIN while examinee is STANDING (measure circumference and specify in inches)

Initial Reading

Repeat Reading

VITAL SIGNS

Pulse

If initial BP >140/90

If initial pulse >100

EXAMINING PHYSICIAN

BODY MEASUREMENTS

Height:__________inches (without shoes) Weight:_____________ pounds

Page 9 of 12 Rev. Mar. 5, 2012

Normal Abnormal Normal Abnormal Head, face, neck (thyroid) Ocular motility Nose/sinuses Ophthalmoscopic findings Mouth/throat Speech Pupils equal/reactive

Physician's Comments (explain abnormalities or contraindications in space below):

Normal Abnormal Lungs/chest Heart (murmur, irregular beats) Vascular (varicosities) EKG (Attach EKG with interpretation.)

Chest X-ray (Refer to TB Screening Form for xray requirements) Chest X-ray Not Performed at this time; indicate by checking box:

Physician's Comments (explain abnormalities or contraindications in space below):

Normal Abnormal Upper extremities (strength) Upper extremitites (range of motion) Lower extremities (strength) Lower extremities (range of motion) Feet/Toes Hands/Fingers Spine Flexibility Deep tendon reflexes Other neurological

Physician's Comments (explain abnormalities or contraindications in space below):

Normal Abnormal Hernia (males only; Normal = no hernia) Abdomen, viscera Lymphatic Skin (scars/unique markings) Mental/emotional affect (describe, if abnormal) Other: (describe, if abnormal)

OTHER MEDICAL SYSTEMS

Physician's Comments (explain abnormalities or contraindications in space below):

MUSCULOSKELETAL FINDINGS

EXAMINING PHYSICIAN

CARDIO/PULMONARY

HEAD AND NECK

Page 10 of 12 Rev. Mar. 5, 2012

(Check the topics discussed with the examinee during the physical examination.)

Lipids Hearing protection Hypertension Other protective equipment Exercise Job stressors Obesity Immunizations Smoking cessation Vision referral Alcohol use Other referral

(Please do not include any conclusions regarding fitness for duty. This service will be provided by the Agency Medical Review Officer.)

NAME OF EXAMINING PHYSICIAN: (Please print or type.)

PHYSICIAN'S SIGNATURE: DATE:

EXAMINING PHYSICIAN

PHYSICIAN'S SUMMARY OF SIGNIFICANT MEDICAL FINDINGS AND RECOMMENDATIONS

MD or DO MUST sign in indicated spaces.

No PA, NP, LPN, RN, or other signatures accepted -- MD or DO ONLY

EDUCATION OR REFERRAL

Page 11 of 12 Rev. June 12, 2012

DATE:

check test used check test used

□ I wear contacts

□ I wear glasses

Signature of Examiner Date Telephone Number Printed Name of Examiner

APPLICANT'S NAME:

FAR Both 20/ ____ Right 20/ ____ Left 20/ ____

CORRECTED VISION (Snellen Units)

APPLICANT ID#:

NEAR Both 20/ ____ Right 20/ ____ Left 20/ ____

FAR Both 20/ ____ Right 20/ ____ Left 20/ ____

VISION TESTING

NEAR Both 20/ ____ Right 20/ ____ Left 20/ ____

TEST ADMINISTRATOR PLEASE NOTE: If the vision testing method only tests to 20/200, state "worse than 20/200." Do NOT use symbols (less than "<" or greater than ">") when documenting visual acuity scores.

____% Shepard-Fry

OR

**All plates must be tested**

Document the number of correct responses above

□ Pseudoisochromatic Plates

□ I do not wear corrective lenses**APPLICANT CORRECTIVE

LENS INFORMATION**

Check all boxes to the right that apply to you: →

UNCORRECTED VISION ( Snellen Units)

Total _____° Total _____°

VISUAL ACUITY TESTING

IF EXAMINEE WEARS CORRECTIVE LENSES: TEST BOTH UNCORRECTED AND CORRECTED VISION

IF EXAMINEE DOES NOT WEAR CORRECTIVE LENSES: TEST ONLY UNCORRECTED VISION

CONTACT WEARERS MUST REMOVE CONTACTS FOR UNCORRECTED VISUAL ACUITY TESTING

**ATTACH COMPLETED COLOR VISION SCORE SHEET**

□ Ishihara plates

**All plates must be tested**

Nasal _____° Nasal _____°

Temporal _____° Temporal _____°

Right Left

PERIPHERAL VISION

____ Seconds of Arc

OR

OR

□ Farnsworth D-15

DEPTH PERCEPTION

□ I wear corrective lenses for seeing close up

□ I wear corrective lenses for seeing far away

COLOR VISION

Document the number of correct responses above.

____ of ____ total number

□ Titmus □ Other __________

____ of ____ total number

Document the number of correct responses above.

____ of 14 plates correct

Page 12 of 12 Rev. June 12, 2012

APPLICANT'S NAME: APPLICANT ID#: DATE:

Plate Normal Response

Applicant Response

1 12

2 8

3 5

4 29

5 74

6 7

7 45

8 2

9 x

10 16

11 Traceable

12 35

13 96

14 Can trace 2 lines

EXAMINER'S PRINTED NAME:

14 PLATE ISHIHARA TESTING

Instructions: Record the applicant's response (actual number/response stated by the examinee) in the appropriate space under "Applicant Response" column. Total the correct responses and document the number correct on the exam paperwork. For example, if the applicant has all correct responses, document 14 of 14 on the Vision Test Exam form.

EXAMINER'S SIGNATURE: