RHRP-II Attachment 20 - USAFR RCHRA Form.pdf

Reserve Component Health Risk Assessment (RCHRA) (This form is subject to the privacy Act of 1974 – Use Blanket PAS – DD Form 2005)

AUT HORI T Y : 10 U.S.C., 8 013 , as implemented by Air Force Instruction 48 -123 .

PURPOSE: To collect personal information from military Reserve Component (RC) personnel to assess their ability to perform routine fitness testing, their individual deployment readiness, and overall RC deployment readiness.

ROUT I N E USE(S): To assess the safety of your performing routine fitness testing. To screen for conditions that may interfere with your ability to deploy and meet mission req uirements. To collate data on overall RC capability to deploy and meet mission req uirements. In addition to those disclosures generally permitted under 5 USC 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside DoD as a routine use pursuant to 5 USC 552a(b)(3 ) as follows: The Department of the Air Force “ Blanket Routine Uses” set forth at the beginning of the Air Force’s compilation of systems of records notices apply to this system. This information will be kept in your medical record and summary results will be provided to you upon completion of the Reserve Component Periodic H ealth Assessment (RCPH A).

D I SCL OSURE: Disclosure of this information is req uired by Title 10,Chapter 51, Section 1004 of the United States Code. Giving false information concerning current health status is a punishable offense and can result in administrative action. IAW AFI 48 -123 , paragraph 14.4.2, each member is responsible for promptly reporting a disease, injury, operative procedure or hospitaliz ation not previously reported to his or her commander or supervisor.

Personnel D ata N ame/Rank SSN Age Date of Birth Gender

H ome Street Address City State Z ip Code

Unit Duty Section Base Duty AFSC ASC

Primary E mail Address H ome Phone Duty Phone

Civilian O ccupation

Active (AGR)

Guard/Reserve

Traditional

Reservist/Guardsman

Individual (IMA)

Mobiliz ation Augmentee

Air Reserve

Technician

O ther Specify

Traditional ARC: H ow many days have you performed military duty this year (ex cluding IDT)? Days

Are you a family member of an active duty military member entitled to care through military channels? Y es N o

Racial Background

American Indian/Alaska N ative Asian/O riental Black, H ispanic

Black, N on-H ispanic Pacific Islander W hite H ispanic

W hite, N on-H ispanic O ther (Specify)

Health Statu s Q u estionnaire– I nstru c tions

Mark the appropriate response to each number q uestion and sign the form after reading it carefully. Continue on the reverse side or attach comments or documentation if necessary. Positive responses which are not fully ex plained or which may effect your medical q ualifications for continued military duty will req uire an interview and further documentation. Y ou may also be req uired to provide supporting civilian medical and dental documentation for inclusion in your medical records.

N OT E: T his information is for offic ial and med ic ally – c onfid ential u se only and w ill not b e released to u nau thoriz ed persons.

1. O verall Self-Assessment of H ealth is E x cellent V ery Good Good Fair Poor

2. Are you on a renewable flying or worldwide duty waiver for any medical reason? Y es N o

3 . Do you have any allergies to medications, foods, or airborne substances? Y es N o

L ist all known allergies:

RCPHA T est F orm, 2 0 0 1 0 5 0 1

4. (a) Do you regularly take any prescription medication(s)? Yes No

(b) Do you regularly take any over the counter medication(s)? Yes No

(c) Do you regularly take any dietary supplement(s)? Yes No Medication(s) Name and why taken

5. During the last year have you taken medication or seen a health care provider for any of the following conditions?

Chest pain/angina Yes No Shortness of breath Yes No Anxiety/depression Yes No

Inflammatory bowel disease Yes No Seizure Disorder Yes No

If you require medications for any of the above, have the medications been listed in block # 5. Yes No

Does the use of these medications control your symptoms? (If No please explain below) N/A Yes No

6 . During the last year have you been told that you have high blood pressure? Yes No

7. Since your last AF Form 895, RCPHA, or Physical Examination have you had chest pains, pressure, or discomfort either with physical activity or when at rest? Yes No

8. Have you ever had irregular heartbeats that have concerned you? Yes No

9. Have you ever had a heart attack? Yes No

10. Have you had a heart operation (bypass, angioplasty, etc.)? Yes No

11. Is there a family history of heart attack in a parent, sibling, aunt or uncle before the age of 55? Yes No

12. Have you been told you have high blood sugar or /diabetes? Yes No

How is it controlled? (v all that apply): None of the following Insulin Diet/Exercise control Oral Medication

13. Have you been told you have problems with blood cholesterol? Yes No

14. Do you use any tobacco products? If no, skip to question 15. Yes No

Type- (check all that apply): Pipe Cigar Smokeless Cigarettes

How many packs of cigarettes per day? Less than one One Two Three or more

How many years have you been using tobacco products? Less than one One-Five Six-Ten More than Ten

RCPHA Test Form, 20010501

Date Name/Rank SSN

15. Do you ever experience shortness of breath at rest, walking or with only moderate exertion? Yes No

16. Have you ever been told you have asthma, bronchospasm, or reactive airway disease? Yes No

17. Do you engage in a program of regular aerobic physical fitness 20 minutes 3 times per week? Yes No

Light Exercise Moderate Exercise Heavy Exercise

18. Do you have a physical condition that precludes brisk walking or running for 1 to 3 miles? Yes No

19. Has your treating physician placed you on restricted activity? Yes No

If yes, explain (include length of time and time of year restrictions apply if known)

20. Do you have any orthopedic problems that prevent regular exercise or become bothersome during exercise? Yes No

21. Is there a history of cancer in your family? Check all that apply. Breast

a. Do you consume alcoholic beverages? If no, skip to question 22. Yes No

b. Have you ever felt you ought to cut down on your drinking? Yes No

c. Have people annoyed you by criticizing your drinking? Yes No

d. Have you ever felt bad or guilty about your drinking? Yes No

e. Have you ever had a drink first thing in the morning (eye opener) to steady your nerves or get rid of a hangover? Yes No

22. Are you on any medications for depression, ADD/ADHD or any other psychiatric condition? Yes No

23. Do you have any problems with your eyes, vision or prescription glasses (check all that apply)? Yes No

Blurred Vision Double Vision Blind Spots Night Blindness

Glare Glaucoma Glasses more than 2 years old

24. Have you had any of the following types of eye surgery (check all that apply)? Yes No

RK PRK LASIK Implants Other Specify:

25. Have you gained or lost more than 15 pounds in the past year that cannot be explained by change in diet and exercise? Yes No

26. Have you noticed blood in your stool or significant changes in your bowel habits? Yes No

27. Have you been advised to eat a special diet? Yes No

28. During the past year have you missed more than 7 days from work due to illness or injury? Yes No

29. Do you have a non-military job or hobby which exposes you to loud noise? Yes No

30. Do you have a non-military job or hobby which exposes you to hazardous chemicals? Yes No

Name and/or type of chemical(s)?

31. Do you use hearing aid(s)? Yes No

32. Do you routinely forget to wear proper protective gear for sports, hobbies, or work (e.g., helmets, goggles, ear plugs, gloves, etc.)? Yes No

33. Do you routinely forget to fasten your seat belt? Yes No

34. Have you seen a health care provider during this past year? Yes No

If yes how many visits: One - Two Three - Six Seven - Ten More than Ten

35. Excluding pregnancy have you been a patient in the hospital overnight/or had any outpatient surgical procedure or been administered intravenous medication in the hospital during the past year? Yes No

36. Have you been treated for any other medical conditions since you completed your last RCPHA or

AF Form 895? Please list conditions below. Yes No

Females Only Complete Blocks 37 – 41

37. Are you pregnant? Yes No

38. Was your last PAP Smear abnormal? Yes No

39. Have you ever had an abnormal breast lump or mammogram? Yes No

40. Do you perform self-breast examination (SBE) at least monthly? Yes No

41. If no longer having menstrual periods or had a total hysterectomy, have you been advised regarding osteoporosis prevention? Yes No

I understand that disclosure of this information is required by Title 10,Chapter 51, Section 1004 of the United States Code. Giving false information concerning current health status is a punishable offense and can result in administrative action. IAW AFI 48-123, paragraph 14.4.2, each member is responsible for promptly reporting a disease, injury, operative procedure or hospitalization not previously reported to his or her commander or supervisor.

Typed or Printed Name Examinee Signature Date

Notes:

Typed or Printed Name Physician or Examiner Signature Date