attmt__3_Employee_Medical_Examination_and_History_Report.pdf

Page 1 of 10 Rev. Mar. 5, 2012

EMPLOYEE'S NAME (Last, First, Middle Initial) SOCIAL SECURITY NUMBER:

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)

NAME AND ADDRESS OF EXAMINING FACILITY:

PHONE NUMBER: (including area code)

AGENCY USE ONLY

DATE OF EXAMINATION:

NAME OF EXAMINING PHYSICIAN:

MEDICAL EXAMINATION AND HISTORY REPORT

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

Employee Complete all portions of this form before reporting for the medical examination. Failure to submit to the examination or failure to make full and open disclosure of any current or past medical conditions, including incomplete, misleading or inaccurate information may be grounds for disqualification, disciplinary, or adverse action against the employee. Please print or type. Each "yes" answer to a medical history question requires that you provide a brief explanation in the comment section provided. This examination is being conducted for employment purposes only; it does not substitute for a periodic health examination conducted by your private provider.

EXAMINING FACILITIES: (Do NOT bill examinee for exam). Conduct medical exam and all other required services in accordance with instructions provided by the contracting organization. Please print or type.

Rev. Mar. 5, 2012

EMPLOYEE's NAME: SSN: 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 10 Rev. Mar. 5, 2012

EMPLOYEE's NAME: SSN:

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

APPLICANT'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……………………...…………………

Back surgery………....…………………………………………..

Diabetes……..………………………………..…………..……...

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

***Note to Examining Physician: All "yes" responses require detailed comments by employee 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………………………...………………

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

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

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

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

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

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

Anemia………….……………………………..…………….…….

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

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

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

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

Hernia…………………………………………….………………...

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

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

Able to work during a migraine?

If yes, how often?______

Page 4 of 10 Rev. Mar. 5, 2012

EMPLOYEE's NAME: SSN: 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

MEDICAL HISTORY

VISION AUDIO

b. How often is inhaler used? ____ times yearly

History of asthma

EMPLOYEE'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 employee and examining physician. Examining physician comments should be recorded on page 7.***

a. Date of last ER visit or hospitalization:_______

CARDIO-PULMONARY

Page 5 of 10 Rev. Mar. 5, 2012

EMPLOYEE'S NAME: SSN: DATE:

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)

EMPLOYEE'S SIGNATURE: DATE:

WITNESS' SIGNATURE: DATE:

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

Applicant 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.

OTHER MEDICAL CONSIDERATIONS

past -- number of years since quitting

Page 6 of 10 Rev. Mar. 5, 2012

Are you familiar with the physical requirements of your current position?

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

Do you have any lifting restrictions? If yes, answer next question Yes No What is the maximum number of pounds you are allowed to lift? _______ lbs

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

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

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

___ Frequently

FITNESS QUESTIONNAIRE

times per week minutes

Over the last six weeks, on average:

___ 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……………………………………..

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

___ Never or Rarely

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

Never or Rarely (less than 2/year)

Occasionally (Once every 2 months)

___ Occasionally ___ Occasionally

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 10 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 examinee 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 applicant 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 applicant or others, degree of diabetic control, and basis for this conclusion.

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

EXAMPLES:

1 Examinee 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 Exaninee 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 examinee:

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 10 Rev. Mar. 5, 2012

Waist

Physician's Comments:

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

Repeat Reading

VITAL SIGNS

Pulse

Blood PressureReadings

If initial BP >140/90

If initial pulse >100

Initial Reading

(measure circumference and specify in inches)

EXAMINING PHYSICIAN

BODY MEASUREMENTS

Height:__________inches (without shoes) Weight:_____________ pounds

Measure AGAINST THE SKIN while examinee is STANDING

Page 9 of 10 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)

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 10 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