RHRP-II Attachment 16 - ARMY PHA Form.pdf

DEMOGRAPHICS

Name: (First) (Middle) :NSS)tsaL(

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Address 2: Gender: Male Female Date of Birth:

Home Phone: Component: Active Army Army Reserve Army National Guard

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:liamE:enohP lleC TRICARE Remote Use: Yes No

ALLERGIES Are you allergic to any of the following? If Yes, you MUST state if the reaction is mild, moderate, or severe and the Provider MUST comment.

None Reaction:

Mild Moderate Severe Provider Comments

Milk � � �

Eggs � � �

Iodine � � �

Latex � � �

Adhesive Tape � � �

Bee Stings � � �

Shell Fish � � �

Nickel � � �

Nuts � � �

Other (List)

Medicine Allergies Are you allergic to any of the following? If Yes, you MUST state if the reaction is mild, moderate, or severe and the Provider MUST comment.

None Reaction:

Mild Moderate Severe Provider Comments

Sulfa Drugs � � �

Vaccines � � �

Penicillin � � �

Codeine � � �

Aspirin � � �

Other (List)

Periodic Health Assessment V201103 Page 1 of 8

OVERALL HEALTH If Yes to any question, both Soldier and Provider MUST supply comments.

1. Do you currently have or have you had dental problems? Yes No

Soldier Comments:

Provider Comments:

2. Have you been seen or treated by a health care provider since your last military exam? Yes No

Soldier Comments:

Provider Comments:

3. Have you been hospitalized or had surgery since your last military exam? Yes No

Soldier Comments:

Provider Comments:

4. Are you taking any over the counter medications, prescription medications, and/or supplements? Yes No

4a. If Yes Yes No

List medications:

5. Are you currently receiving any VA disability, workman’s compensation, or other type of compensation for health or physical reason? Yes No

Soldier Comments:

Provider Comments:

take alternate APFT event, or keeps you from doing your military job duties? Yes No

Provider Comments:

Name: ________________________________________________________ Full SSN: ___________________________

Periodic Health Assessment V201103 Page 2 of 8

CURRENT HEALTH Do you have or have you ever had any of the following symptoms?

CURRENT HE ALTH If Yes, you MUST state if you are currently being treated and supply comments. The Provider MUST also comment.

Symptom Do you have or have you ever had:

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Heart trouble/chest pain ��Yes ��No ��Yes ��No

Heart murmur ��Yes ��No ��Yes ��No

High blood pressure ��Yes ��No ��Yes ��No

Rheumatic fever ��Yes ��No ��Yes ��No

Stroke ��Yes ��No ��Yes ��No

Frequent headaches ��Yes ��No ��Yes ��No

Thyroid disease ��Yes ��No ��Yes ��No

Back pain ��Yes ��No ��Yes ��No

Kidney disease ��Yes ��No ��Yes ��No

Liver disease ��Yes ��No ��Yes ��No

Sinus disease ��Yes ��No ��Yes ��No

Hives/rash ��Yes ��No ��Yes ��No

Name: ________________________________________________________ Full SSN: ___________________________

Periodic Health Assessment V201103 Page 3 of 8

Do you have or have you ever had any of the following symptoms?

If Yes, you MUST state if you are currently being treated and supply comments. The Provider MUST also comment.

Symptom Do you have or have you ever had:

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Asthma/hay fever ��Yes ��No ��Yes ��No

Diabetes ��Yes ��No ��Yes ��No

Tuberculosis ��Yes ��No ��Yes ��No

Joint pain ��Yes ��No ��Yes ��No

Chronic pain ��Yes ��No ��Yes ��No

Epilepsy ��Yes ��No ��Yes ��No

Ulcers ��Yes ��No ��Yes ��No

Anemia ��Yes ��No ��Yes ��No

Cancer ��Yes ��No ��Yes ��No

Mental Health Concerns ��Yes ��No ��Yes ��No

Other (please specify)

��Yes ��No ��Yes ��No

Periodic Health Assessment V201103 Page 4 of 8

Name: ________________________________________________________ Full SSN: ___________________________

PREVENTIVE HEALTH – If Yes is checked, the Provider MUST enter a Referral or check Education.

Referral Options: Military Treatment Facility; Division/Line Based Medical Resource; VHA; Vet Care; TRICARE Provider; Contract Support; Community Service; Primary Care Manager; Soldier Declined; Civilian Behavioral Health; Military One Source; Other.

Tobacco Use:

Do you smoke any kind of tobacco products?

Yes

No

Provider Only:

Referral: ________________________________________________________

Education

If Yes, you MUST answer the following questions:

1. How soon after you wake up do you smoke your first cigarette?

After 60 minutes 6-30 minutes

31-60 minutes Within 5 minutes

2. Do you find it difficult to refrain from smoking in places where it is forbidden?

Yes

No

3. Which cigarette would you hate most to give up?

The first in the morning

Any other

4. How many cigarettes per day do you smoke?

10 or less 21- 30

11 - 20 31 or more

5. Do you smoke more frequently during the first hours after awakening than during the rest of the day?

Yes

No

6. Do you smoke even if you are so ill that you are in bed most of the day?

Yes

No

Do you dip or chew?

Yes

No

Provider Only:

Referral: ________________________________________________________

Education

If Yes, you MUST answer the following questions:

1. How soon after you wake up do you place your first dip?

After 60 minutes 6-30 minutes

31-60 minutes Within 5 minutes

2. How often do you intentionally swallow tobacco juice?

Always Sometimes Never

3. Which chew would you hate most to give up?

The first in the morning Any other

4. How many cans/pouches per week do you use?

More than 3 2 - 3 1

5. Do you chew more frequently during the first hours after awakening than during the rest of the day?

Yes

No

6. Do you chew even if you are so ill that you are in bed most of the day?

Yes

No

Alcohol Use:

How often do you have a drink containing alcohol?

�� Never 2-3 times a week

�� Monthly or less 4 or more times a week

�� 2-4 times a month

Provider Only:

Referral: ________________________________________________________

Education

If you answer anything other than Never, you MUST answer the following questions:

1. How many drinks containing alcohol do you have on a typical day when you are drinking?

1 - 2 7 - 9

3 - 4 10 or more

5 - 6

2. How often do you have six or more drinks on one occasion?

Never Weekly

Less than monthly Daily

Monthly

3. Do you use alcohol more than you mean to?

Yes

No

4. Have you felt that you wanted to or needed to cut down on your drinking?

Yes

No

Periodic Health Assessment V201103 Page 5 of 8

Name: ________________________________________________________ Full SSN: ___________________________

BEHAVIORAL HEALTH

Referral Options: Military Treatment Facility; Division/Line Based Medical Resource; VHA; Vet Care; TRICARE Provider; Contract Support; Community Service; Primary Care Manager; Soldier Declined; Civilian Behavioral Health; Military One Source; Other.

Mental Health:

Little interest or pleasure in doing things? Yes No

Feeling down, depressed, or hopeless? Yes No

If you answer Yes to either question, you MUST answer the following questions:

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things? Not at all Several days More than half

Nearly every day the days

Feeling down, depressed, or hopeless? Not at all Several days More than half

Nearly every day the days

Trouble falling asleep or staying asleep, or sleeping too much? Not at all Several days More than half

Nearly every day the days

Feeling tired or having little energy? Not at all Several days More than half

Nearly every day the days

Poor appetite or overeating? Not at all Several days More than half

Nearly every day the days

Feeling bad about yourself, or that you are a failure, or that you have let yourself or your family down? Not at all Several days More than half

Nearly every day the days

Trouble concentrating on things, such as reading the newspaper or watching television? Not at all Several days More than half

Nearly every day the days

Moving or speaking so slowly that other people could have noticed. Or around a lot more than normal?

Not at all Several days

More than half Nearly every day the days some way? Not at all Several days More than half

Nearly every day the days it for you to do your work, take care of things at home, or get along with other people?

Not difficult Somewhat Very Difficult � Extremely difficult at all difficult

Provider Only - Enter a Referral or check Education if needed.

Referral: ________________________________________________________

Education

Additional Comments:

Periodic Health Assessment V201103 Page 6 of 8

Name: ________________________________________________________ Full SSN: ___________________________

FAMILY HISTORY – Choose all that apply for each family member. You MUST enter a condition from the list for each checked box.

Cancer:

Lung Breast Colon Prostate Bone Brain Lymphatic Skin Ovarian Cervical Testicular Renal Pancreatic Esophageal Liver Multiple Other None Unsure Unknown

Cardiovascular:

Myocardial infarction (Heart Attack) Cerebral vascular accident (Stroke) Coronary artery disease Hypertension Cardiac arrhythmia Congestive heart failure Hypercholesterolemia Ischemic heart disease Cardiomyopathy Sudden cardiac death Aortic aneurysm Multiple Other None Unsure Unknown

Diabetes:

Type 1 Type 2 None Unsure Unknown

Mental Health:

Generalized anxiety disorder Depression Bipolar disease Schizophrenia Obsessive compulsive disorder

Split personality disorder Personality disorder Adjustment disorder Eating disorder Tourette syndrome Agoraphobia Autism

Suicide Multiple Other None Unsure Unknown

Chemical Dependency:

Alcohol Cocaine/crack Heroin Marijuana Methamphetamine Narcotics Glue/solvents

LSD

Benzodiazepines Ecstasy Multiple Other None Unsure Unknown

��None ��None ��None ��None ��None

��Father ��Father ��Father ��Father ��Father

��Mother ��Mother ��Mother ��Mother ��Mother

��Sibling ��Sibling ��Sibling ��Sibling ��Sibling

Mother’s Side Mother’s Side Mother’s Side Mother’s Side Mother’s Side

��Grandmother ��Grandmother ��Grandmother ��Grandmother ��Grandmother

��Grandfather ��Grandfather ��Grandfather ��Grandfather ��Grandfather

Father’s Side Father’s Side Father’s Side Father’s Side Father’s Side

��Grandmother ��Grandmother ��Grandmother ��Grandmother ��Grandmother

��Grandfather ��Grandfather ��Grandfather ��Grandfather ��Grandfather

Periodic Health Assessment V201103 Page 7 of 8

Name: ________________________________________________________ Full SSN: ___________________________

EVALUATION – This portion is to be completed by the Provider.

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Cholesterol :

Recorded _______________ Recorded HDL _______________

Mammogram

Pap Smear

Colorectal Cancer Screening :

Three Card Fecal Occult Test

Sigmoidoscopy

Colonoscopy – includes CT colonoscopy

Blood Pressure:

Systolic: _________________ Diastolic: _______________

Visual Acuity Test:

20/ _______________

Chlamydia

Gonorrhea

EKG

Framingham – This portion is to be completed by the Provider.

Blood Pressure: Untreated Treated :ksiR detaluclaC mahgnimarF

PULHES – This portion is to be completed by the Provider.

PULHES Height (Inches): Weight:

P __________ U __________ L __________ H __________ E __________ S __________

Physical Category Codes: (Enter their priority 1-6 behind each box checked)

A ____ B ____ C ____ D ____ E ____ F ____ G ____ H ____ J ____ L ____

S ____

M ____

N ____ P ____ T ____ U ____ V ____ W MMRB ____ X ____ Y ____

Deployable to an austere environment within the next 6 months? Pregnant? Due Date:

��Yes ��No ��Yes ��No

Additional Comments:

Must be performed by an MD, DO, PA or NP

Provider Name and Credentials Date

Provider Signature

X

Periodic Health Assessment V201103 Page 8 of 8

Name: ________________________________________________________ Full SSN: ___________________________