RHRP-II Attachment 18 - USCGR PHA Form.pdf

U.S. COAST GUARD PERIODIC HEALTH ASSESSMENT

SECTION 1: VITALS ________ year old male female reports for an annual Periodic Health Assessment (PHA) which includes record review/verification, assessment and counseling of avoidable health risk factors, clinical preventive services (CPS) recommendations, deployment/operational health history, and individual an medial readiness (IMR) assessment.

Height (inches)

Weight (pounds)

BMI

Temperature

Respirations

Blood Pressure

Pulse

Prescription Lenses (two pair)

Ballistic Eyewear

Gas Mask Inserts

Medical Alert Tags

SECTION 2: IME

VERIFICATION

Yes No NA

Yes No NA

Yes No NA

Yes No NA

SECTION 5: HEALTHCARE PROVIDER ASSESSMENT

3. Health Risk Assessment reviewed. Health Risk Assessment Level: High Medium Low

1. Updated DD 2766 Sections (circle): 1 2 3 4 5 6 7

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

Location:

9. Any unresolved operational or deployment health issues? Yes No

10. Other health concerns?

No health issues identified requiring a focused exam.

Focused exam required for (document on separate SF 600):

SECTION 6: DUTY STATUS ASSESSMENT

SECTION 7: COMMENTS/SIGNATURES

On Limited Duty Yes No Medical Board Pending WaiversYes No Yes No

Comments for Yes:

Additional Comments:

Member informed that completion of recommended test/immunizations/screenings shall be performed within the next 30 days and he/she is personally responsible for achieving/maintaining individual readiness. Member received health risk prevention/health lifestyle counseling and voiced understanding.

Member Name (print)

Patient Name (Last, First, MI) SSN DOB

RHRP USE ONLY

SECTION 3: VISION

Vital Signs Noted.

Remarkable for:

None

Other: _______________

Visual Acuity Corrected:

OD __________

OS __________

Binocular __________

Visual Acuity Uncorrected:

OD __________

OS __________

Binocular __________

Finger Rub Test:

Left Pass / Fail

Right Pass / Fail

Yes No

Member Signature

Provider Name & Credentials (print) Provider Signature

Date

Date

1. Total Cholesterol ______________ HDL ______________

2. Cardiovascular Screening (Framingham 10-year risk if over 40 y/o) __________________________________________________________

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

4. Additional Comments:

Date

Treated Untreated

SECTION 4: AUDIO

2. Does Member smoke? Yes No

5. Clinical Preventive Services recommended. Pap Chlamydia Mammogram Clinical Breast Exam

Colorectal Prostate Cholesterol Testicular Exam Other:

N/A

6. Referred to PCM for: Current Medications Chronic Medical Condition Current Illness/Injury

Fitness for Duty Issue Weight Problem Clearance Other:

N/A

4. Referred for consultation/follow-up on: Tobacco Use Physical Activity ETOH Use Nutrition

Mental Health Other:

N/A

If Yes, explain:

* Must be performed by MD, DO, PA, NP

USCGR 04-09

X

X

7. Has Member ever tested positive for TB? Yes No

If Yes: Asymptomatic Symptomatic

List symptoms: