RHRP-II Attachment 21 - RHRPII-5 Occ Health Form.pdf

RHRP 5; Rev 1/08

RESERVE HEALTH READINESS PROGRAM

MEDICAL SURVEILLANCE MANAGEMENT PROGRAM

HEALTH HISTORY AND PHYSICAL EXAMINATION FORM

Part I. Personal Information and Medical History (to be completed by the employee before the examination

For RHRP Office Use Only Agree. #: ________________________ OHC/Z-code:____________________ Source of Exposure History:

Agency Set or Standard IH Interview Part II, Sec. 2 MSMP Form

A comprehensive history is an important part of your medical record. Please complete Part I and II of this questionnaire by placing a check mark ( ) in the appropriate spaces or printing other information where requested (use black or blue ink). Return form to the site where your exam will be done. Please see the Privacy Act Notice on the next page.

IDENTIFICATION Today’s Date Sex: Check One: [ ] Hispanic [ ] Male [ ] Black (non-Hispanic) [ ] Asian [ ] Female [ ] White (non-Hispanic) [ ] Pacific Islander

LAST NAME ELDDIM)semankcinoN(TSRIF [ ] American Indian/Alaskan Native ytiCetatSyrtnuoC:HTRIBFOECALPETADHTRIB.ONYTIRUCESLAICOS

ETS’ROSIVREPUSROSIVREPUSFOEMANTINULANOITAZINAGRONOISIVIDYCNEGA:REYOLPMERUOY LEPHONE NO.

.ONENOHPELETKROWRUOYYTILICAF/GNIDLIUBKROWRUOYREBMUNSEIRESBOJDNAELTITBOJMPOLAICIFFORUOY

.ONENOHPELETEMOHPIZETATS,YTICSSERDDAGNILIAMEMOHRUOY

MEDICATIONS

List ALL medications (including prescription, non-prescription, vitamins and herbal preparations) you currently take:

SOCIAL HISTORY

Have you ever used tobacco? [ ]Yes [ ]No

If "yes", When: [ ] Current [ ] Past - years since quitting?

Type: [ ] Cigarettes [ ] Pipe/Cigar [ ] Snuff/Chewing Amount per day? _________ For how many years?

What is your average alcohol consumption in a week? ______ drinks (1 drink = 12 oz. beer, 1 glass wine or 1.5 oz liquor)

If you drink alcohol, what is your usual pattern?

[ ] Weekdays [ ] Weekends [ ] Both

MEDICAL HISTORY

Which of the following conditions have you ever had?

Enter year of diagnosis, if known, or place if unknown.

[ ] Allergies Specify:

[ ] Anemia

[ ] Asthma [ ] Herniated disc

[ ] Broken bones [ ] High blood pressure

[ ] Cancer history [ ] Head Injury

[ ] Claustrophobia [ ] Kidney disease

[ ] Collapsed lung [ ] Loss of consciousness

[ ] Diabetes [ ] Migraines

[ ] Denture use [ ] Positive skin test for TB

[ ] Emphysema [ ] Prostate problems

[ ] Heart attack [ ] Ruptured ear drum

[ ] Heart murmur [ ] Seizures

[ ] Hepatitis [ ] Thyroid trouble

Other medical disorders - Specify:

Year of last tetanus booster: ___________

Year of last chest x-ray: _______________

Have you received Hepatitis B vaccine? [ ] Yes [ ] No

If “yes”, number of shots: [ ] 1 [ ] 2 [ ] 3 Year completed: _______

HOSPITALIZATIONS AND SURGERIES

YEAR REASON (continue on the back, if more space is needed)

LEISURE ACTIVITIES

In which of the following hobbies/activities do you participate?

[ ] Painting [ ] Ceramics/Pottery [ ] Guns/hunting

[ ] Gardening [ ] Refinishing [ ] Stained glass

[ ] Auto/boat repair [ ] Power tool usage [ ] Other (specify below):

Do you use safety equipment when you engage in these activities? [ ]Yes [ ] No

OTHER QUESTIONNAIRES [RHRP Office Use Only] Please indicate those additional questionnaires that are necessary, based on the examinee’s exposure history and agency requirements. If additional questionnaires are completed, attach them to this Health History form, and indicate “Completed” in the space, below.

Needed Completed

Audiogram History / Report [ ] [ ] Tuberculosis Screening Form [ ] [ ] Cadmium Exposure History [ ] [ ] Reproductive Health Effects History [ ] [ ] Initial Asbestos Medical Questionnaire [ ] [ ] Periodic Asbestos Medical Questionnaire [ ] [ ]

Privacy Act Statement

The collection and use of this information is authorized by 5 U.S.C. 7901 (Health Service Programs) and 29 U.S.C. 657 (Occupational Health and Safety; Record Keeping). The information will become part of your official Employee Medical File, and will be used to assist Reserve Health Readiness Prorgam in carrying out its occupational health services responsibilities under one or more interagency agreements with your employing agency, and for other official purposes and routine uses as described in Privacy Act systems notice OPM/GOVT-10 (Employee Medical File System Records). Providing the requested information is voluntary. Not providing the information may affect the availability and quality of health services rendered to you, and may also affect the completeness of information used by your agency in making determinations of medically-related employment decisions.

Employee Name:_______________________________________________________ RHRP 5; Rev 1/08

REVIEW OF SYSTEMS - Which of the following have been a problem for you in the last year?

General/Constitutional

[ ] Fever, >100 sllihc/gnirevihS][

[ ] Generalized weakness

[ ] Unexplained weight loss/gain eugitafevissecxE][ sdnalgnellowS][

[ ] Loss of appetite

Eyes noisivniegnahC][

[ ] Itching

[ ] Tearing

Ears, Nose, Throat gniraehytluciffiD][ gnizzub,gnigniR][ elbuortsuniS][

[ ] Sneezing/runny nose sdeelbesoN][

[ ] Difficulty swallowing

Heart/Lungs

[ ] Chest pain or pressure

[ ] Irregular heart beat

[ ] Palpitations/skipped beats

[ ] New or changed cough

[ ] Coughing up blood gnizeehW][

[ ] Shortness of breath

Digestive System

[ ] Nausea/vomiting

[ ] Diarrhea/Constipation (circle one or both ) ecidnuajwolleY][

[ ] Rectal bleeding or black tarry stools

Neurologic/Psychiatric sehcadaeH][

[ ] Dizziness/passing out (circle one or both) noisserpeD][

[ ] Numbness or tingling

[ ] Excessive anxiety

[ ] Insomnia / difficulty sleeping

[ ] Loss of memory

Skin/musculoskeletal sehsaR][

[ ] Moles that changed in size or color niapelcsuM][ niapkcaB][

[ ] Neck pain

[ ] Weakness in arms/legs niaptnioJ][

Genitourinary & Reproductive

[ ] Difficult or painful urination

[ ] Blood in urine

[ ] Difficulty having children

(Men Only)

[ ] Lump in Testicle

[ ] Impotence

(Women Only)

[ ] Irregular periods/spotting

[ ] Miscarriage or stillborn pregnancy

[ ] Breast lump/discharge

[ ] Currently or possibly pregnant

Part II. Occupational and Exposure History (to be completed by the employee before the examination)

Section 1, OCCUPATIONAL HISTORY (Section 2., EXPOSURE HISTORY, is a separate form that also may be required) :bojtnerrucruoyfoseitivitcaehtebircsedylfeirB

How long have you been doing this type of work? _______ years Have you ever been off work more than a day because of work-related illness or injury? [ ] Yes [ ] No yficeps,”sey“fI Have you ever changed jobs or duties due to health problems? [ ]Yes [ ] No If “yes”, specify

If this is your first RHRP medical surveillance exam, list all previous jobs , starting with the one before your current position:

Agency/Company Dates of Employment

(from --- to) sdrazaHcificepSseituDboJ

* Hazards include asbestos, chemicals, dusts, fumes, gases, radiation, vibration, repetitive motion, intense light and loud noise.

* For any asbestos exposure, please indicate the year and place of first exposure, regardless of use of protective equipment:

Examiner’s comments : [All positive responses in the medical history (section 4), hospitalization and surgery (section 5), and review of systems (section 9), above, should be commented upon here.]

Part III. Physical Examination (to be completed by the examiner at the time of the examination)

Physical Examination, Section 1 (Record the results of all services that are provided.)

Vital Signs: (in.) (lb.) / (mm/Hg) ______ ______ _____ __________ Health Center Stamp Height Weight Blood Pressure Pulse Temperature Respirations

Tonometry: O.D: _______mm/Hg Mantoux [ ] _______ mm. induration Stool for [ ] neg x 3 O.S: _______ (PPD) [ ] not done Occult [ ] positive [ ] not done Blood [ ] not done

Best Vision: Testing method screening machine wall/hand held chart

[ ]Uncorrected

Near: OU (both) 20/_______

OD (right) 20/_______

OS (left) 20/_______

Far: OU (both) 20/_______

OD (right) 20/_______

OS (left) 20/_______

[ ] With Correction

Correction Type: Contacts Glasses

Near: OU (both) 20/_______

OD (right) 20/_______

OS (left) 20/_______

Far: OU (both) 20/_______

OD (right) 20/_______

OS (left) 20/_______

Comments:

Peripheral vision (degrees) right Temporal _____

Nasal _____

Total _____ left Temporal _____

Nasal _____

Total _____

Color Vision (test used: ) Number correct:

_____ of _____ tested

Can see red/green/yellow? Yes No

Depth Perception (test type and seconds of arc)

Spirometry:

Actual

FVC

Actual

FEV1

Actual FEV1/FVC Actual

FEF 25-75

%Predicted

FVC

57-52FEFdetciderP%CVF/1VEFdetciderP%1VEFdetciderP%

Comments:

Audiometry:

With hearing aid? No___ Yes___ (Type: ) Frequency 500Hz 1000Hz 2000Hz 3000Hz 4000Hz 6000Hz 8000Hz

Right ear

Left ear

TMs visible (right and left) ? [ ]Yes [ ] No

Standard Threshold Shift present? [ ]Yes [ ] No

Comments:

Physical Examination, Section 2 Not enoDlamronbAlamroN Comment:

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INTERPRETATION OF LAB AND OTHER SCREENING RESULTS

----- -----lamronbA----------lamronbA Clinically Clinically Not Clinically Clinically Not

Normal Insignificant Significant Done Normal Insignificant Significant Done Chem Profile

Liver function [ ] [ ] [ ] [ ] Audiometry [ ] [ ] [ ] [ ]

Renal function [ ] [ ] [ ] [ ] Chest x-ray [ ] [ ] [ ] [ ]

Other chemistries [ ] [ ] [ ] [ ] B-reading [ ] [ ] [ ] [ ]

CBC [ ] [ ] [ ] [ ] EKG [ ] [ ] [ ] [ ]

Urinalysis [ ] [ ] [ ] [ ] ETT (Stress Test) [ ] [ ] [ ] [ ]

ZPP [ ] [ ] [ ] [ ] Spirometry [ ] [ ] [ ] [ ]

Lead (blood) [ ] [ ] [ ] [ ] Tonometry [ ] [ ] [ ] [ ]

Heavy Metal Screen [ ] [ ] [ ] [ ] Visual Acuity [ ] [ ] [ ] [ ]

Plasma Cholinesterase [ ] [ ] [ ] [ ] Stool for Occult Blood [ ] [ ] [ ] [ ]

RBC Cholinesterase [ ] [ ] [ ] [ ] PPD (Mantoux) [ ] [ ] [ ] [ ]

PCBs [ ] [ ] [ ] [ ] Other_____________ [ ] [ ] [ ] [ ]

Comments:

RESERVE HEALTH READINESS PROGRAM

MEDICAL SURVEILLANCE MANAGEMENT PROGRAM

MEDICAL HISTORY AND PHYSICAL EXAMINATION FORM

Part IV. Examiner’s Summary (to be completed by the examiner at the time of the examination)

ASSESSMENT / REFERRAL PLAN

Not --R e f e r r e d---

:stnemmoC Referred Routine Urgent

1. [ ] [ ] [ ]

2. [ ] [ ] [ ]

3. [ ] [ ] [ ]

4. [ ] [ ] [ ]

5. [ ] [ ] [ ]

RECOMMENDATIONS / EDUCATION SUMMARY [Note: this is NOT a clearance summary; see Part V, Report to Employer]

THE FOLLOWING TOPICS AND RECOMMENDATIONS MARKED WITH A “ ” WERE

DISCUSSED WITH THE EMPLOYEE:

noitassecgnikomS][tnempiuqEevitcetorP][ erusopxesotsebsadnagnikomsfosregnaD][ noitpmusnoclohoclapotsroecudeR][noitcetorPgniraeH][ gnineercsrecnacralugernietapicitraP][sessalgytefaS][

)ralucitset,tsaerb(noitanimaxefleS][esurotaripseR][ [noitcetorpnikS/sevolG][ ] Universal Precautions for BBP vA][stlebtaeS][ oid sun exposure/Use sun block [ ] Other __________________ [ ] Other _________________________ etaDerutangiss'renimaxE)tnirp(renimaxEfoemaN

I have received a copy of the summary of my examination and understand the recommendations:

Employee Signature Date

RESERVE HEALTH READINESS PROGRAM

MEDICAL SURVEILLANCE MANAGEMENT PROGRAM

MEDICAL HISTORY AND PHYSICAL EXAMINATION FORM

Part V. Report to Employee (to be completed by the reviewer )

NAME SSN

AGENCY EXAM DATE __________________________

Summary of occupational medicine consultant review:

Confidential report to the employee

The examiner who performed your medical surveillance exam should have discussed important findings of the exam, and made sug-gestions to you about any medical follow-up that was needed. Your medical surveillance exam records also have been reviewed by an occupational medicine consultant, and compared to results from prior medical surveillance exams when these were available.

This form provides the impressions of the medical consultant after reviewing your records, along with the consultant’s recommenda-tions for work modifications and suggestions for follow-up. This confidential information IS NOT shared with your supervisor.

1. Possible health effects from recent workplace exposures:

__None noted

2. Health problems not caused by work, and which do not affect your ability to perform job duties safely and effi-ciently:

__None noted

3. Health problems not caused by work, but which may affect your ability to perform job duties safely and effi-ciently:

__None noted

4. Follow-up needed as part of the medical surveillance exam program (please send to the address given below) __None required

5. Other comments by the occupational medicine consultant

If you have questions, please call me at ______________________________, etaDerutangiSs’reweiveR)tnirP(emaNs’reweiveR

Address

RESERVE HEALTH READINESS PROGRAM

MEDICAL SURVEILLANCE MANAGEMENT PROGRAM

MEDICAL HISTORY AND PHYSICAL EXAMINATION FORM

Part VI. Report to Employer (to be completed by the reviewer)

NAME SSN

AGENCY EXAM DATE __________________________

Medical Opinion: (check all that apply) The employee has been informed of the following medical opinion.

[ ] No medical findings were noted that indicate work-related injury/illness.

Where nonwork-related significant findings were noted, a referral has been made at the employee’s expense.

[ ] Medical findings support a work-related injury/illness or hazardous exposure, see recommendations below.

[ ] Medical findings or exposure history warrant a review of work activities, see recommendations below.

[ ] Decision deferred, additional documentation needed. Please provide the documentation listed below..

[ ] Work limitations recommended. (Specify limitations and re-evaluation date below).

Comments/Recommendations/Limitations:

Limitations should be reevaluated (Date)

Clearances:

[ ] Employee has been cleared for the routine duties outlined in the provided job description.

[ ] Motor Vehicle Clearance (DOT/DMV) Expires [ ] Other. Specify Expires

(e.g.,, crane operator, diver, fire fighter, arduous duty)

Respirator Clearance (select one box and provide comments as appropriate)

This employee has been found to be physically able to use the following (check each [ ] that applies):

(see Respirator Medical Evaluation Questionnaire form for specific types and uses requiring clearance) [ ] Single use, filter mask (four attachment points) [ ] Half-faced cartridge-type, negative pressure [ ] Full-faced cartridge-type respirator, negative pressure [ ] Half-faced powered cartridge-type (PAPR) [ ] Full-faced powered cartridge-type (PAPR) [ ] Self-contained breathing apparatus (SCBA) [ ] Hood/helmet powered cartridge-type (PAPR) [ ] Half-faced/Full-faced/Hood/Helmet

(NOT positive pressure) (positive pressure airline respirator)

When wearing a respirator, the employee has been informed to limit activity level* to the following (check one [ ]):

[ ] Mild Exertion [ ] Moderate Exertion [ ] Heavy Exertion (No specified limitations)

Other limitations needed (if any) when wearing a respirator:

This respirator clearance expires 1 2 3 years from the date below. (If not marked, clearance expires in 1 year) (circle one )

This employee has been found to be physically NOT able to use a respirator

There is insufficient information to make a determination at this time The following additional tests, or medical information, will be required in order to make a determination regarding the safe use of a respirator by this employee:

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* Light/Mild exertion (2-3 METS)= negligible lifting, extended walking (flat surface), extended standing, writing Moderate exertion (4-5 METS) = lifting 10lbs (5 or more lifts/min), fast walking (4mph), gardening/digging, pushing, pulling Heavy exertion (5-10 METS) = jogging (10 minute mile), chopping wood, climbing hills, life-saving activities, firefighting