RHRP-II Attachment 17 - USNR-MFR PHA Form.pdf

NAVMED 6120/4 (Rev. 03/2008)

PERIODIC HEALTH ASSESSMENT (PHA)

S: SUBJECTIVE

Allergies (Medication and other): See Block 1 on DD 2766 Chronic Illnesses: See Block 2 on DD 2766 Medications (Rx / OTC / herbals / supplements / performance enhancers): See Block 3 on DD2766 Hospitalizations/Surgeries since last PHA: See Block 4 on DD 2766 Family History: See Block 6 on DD 2766 Occupational History: See Block 8 on DD 2766

O: OBJECTIVE

Vital Signs noted. Remarkable for:

Visual Acuity: OD:

Physical examination is otherwise deferred.

None Other:

OS: (Consult if worse than 20/40, no contacts)

Health Record Dental Readiness Dental Classification Immunization Record Lab/Path Results Clinical Prev. Services Occupational Health Hearing Assessment

Reviewed Reviewed Reviewed Reviewed Reviewed Reviewed Reviewed

Not Available Not Available Not Available Not Available Not Available Not Available Not Available

Remarkable for:

See Plan See Plan See Plan See Plan See Plan See Plan

Deployment Health: See DD 2766 Deployed since previous PHA?

Post-Deployment Health Assessment (DD 2796) in record?

Post-Deployment Health Reassessment (DD 2900) in record?

Any unresolved deployment-related issues or health concerns?

Comments:

Yes Yes Yes Yes

No No No No

Health Risk Assessment: Completed and reviewed?

Health Risk Assessment Level:

Cardiovascular Screening (Framingham 10-year risk for Event/Death):

Pain Assessment (zero pain to severe): 0 1 2 3 4 5 6 7 8 9 10 Location:

Any other current health concerns?

A: ASSESSMENT

No Med Low

Yes High

PATIENT'S IDENTIFICATION

(Use this space for mechanical imprint telephone number and e-mail address for follow-up):

PATIENT'S NAME (Last, First, Middle Initial) SEX

RANK/GRADE

DATE OF BIRTH

SSN / IDENTIFICATION NO.

RECORDS MAINTAINED AT

STATUS

DATE:

SCREENING:

Height: (inches)

Weight (pounds)

BMI:

Temperature:

Respirations:

deferred deferred

Pulse:

MEDICAL

EQUIPMENT:

Prescription Lenses (two pairs)

Ballistic Eyewear

Gas Mask Inserts

Medical Alert Tags

Y N NA

NANY

NANY

NANY

Blood Pressure:

_____ year old ( ) male ( ) female reports for an annual PHA which includes record review/verification, assess-ment and counseling of health risk factors, clinical preventive services, deployment health history, and individual medial readiness (IMR) assessment.

NAVMED 6120/4 (Rev. 03/2008)

Behavioral Health

FFSC

OB/GYN

Semper Fit

PERIODIC HEALTH ASSESSMENT (PHA) (Continued)

On Limited Duty (LIMDU) Medical Board

Duty Status Assessment No No

LOD

Yes Yes

NPQ

NA

NA

NA

Comments:

Comments:

Comments:TNPQ TNDQ

P: PLAN / P: PREVENTION

1. Updated DD 2766 Sections:

2. Health counseling performed and documented on the DD 2766:

3. Labs ordered for the following:

5. Tuberculosis Screening:

6. Clinical Preventive Services recommended:

Others as required by geographic, occupation, or ISIC Electronic verification complete:

4. Immunizations ordered for the following:

Clinical Breast Exam Other:

Hep A #1 #2 Other immunizations:

Electronic verification complete:

7. Referred to Dental for:

8. Referred to PCM for:

Current Medications / Supplements Other:

9. Referred for Preventive / Healthy Lifestyle Counseling:

Tobacco Use Sexuality

10. Other indicated referrals:

Audiology Chaplain Other:

11. Member readiness reviewed and updated in approved electronic data system Member is fully medically ready and requires no follow-up at this time:

12. Additional Comments:

13.

1 2 3 4 5 6 7 8 9 10 11

NoYes Blood Type and RH G6PD HIV DNA Lipids

NoYes

Hep B #1 #2 #3 (required for all new recruits) TWINRIX ® may be used (3 shots required)

NoYes

PPD Placement: Results:

Pap Chlamydia Mammogram Colorectal Testicular Exam Prostate Cholesterol

Annual T-2 Dental Exam Dental Class 3 Dental Class 4 Bitewings Panograph

Chronic Medical Conditions

Physical Fitness Clearance Deployment-Related Condition

Current Illness / Injury

Physical Activity Other:

Safety Alcohol Use Dental Care Nutrition

OCC HealthDietician Weight Management

Optometry

DAPA

Mental Health

MMR Tdap (1 time booster) or Td IPV Influenza

Member informed that completion of recommended tests / immunizations / screenings is to be performed within the next 30 days, and he/she is personally responsible for maintaining IMR. Service Member received health risk prevention / healthy lifestyle counseling and voiced understanding.

Name (Last, First, MI)

Member Signature:

HM / MDR Signature:

Provider Signature:

Date:

Date:

Date:

Signature, printed name, and credentials

SSNDate of Birth

NoYes NoYes NoYes