PWS Att 4 - Responder Readiness Clearance.pdf

Medical Clearance History Form

Name: _________________________________________________Date:

Past Medical and Surgical History (List any past or current medical complaints, diseases, symptoms, surgeries, procedures or other conditions) Date Condition Current Status

Family History (List any medical conditions of blood relatives including high blood pressure, heart or kidney disease, diabetes, cancer, alcoholism, psychiatric illness or others)

Social History Do you use tobacco in any form? No Yes Do you drink alcohol in any form? No Yes Do you use illegal drugs or misuse other drugs? No Yes

Explain any “yes” answers.

Assessment of Physical Activity Level (Describe type, amount and frequency of physical activity that you complete on a regular basis)

Current Medications (Include prescription, over-the-counter, vitamins, supplements, herbals, others)

Allergies (List and describe medication, food, insect or other allergic reaction or adverse event)

Name: Date:

Immunization History (Give month and year when immunization(s) last completed if known) Tetanus/Diphtheria (required for DSNS team, HST & Quarantine) Hepatitis A (required for DSNS team & HST) Hepatitis B (required for DSNS team, HST & Quarantine) Measles/Mumps/Rubella (required for HST & Quarantine) Varicella (if unknown, must titer) (required for HST& Quarantine) TB Skin Testing (required annually for HST & Quarantine) Influenza (recommended for DSNS & Quarantine) Smallpox (recommended for DSNS & Quarantine) Anthrax_______________________________________

Review of Symptoms in Major Body Systems

HAVE YOU EVER HAD:

YES NO YES NO

1. Frequent or severe headaches? 26. Kidney or prostate disease?

2. Dizzy spells, fainting or blackouts?

27. Diabetes?

3. Epilepsy or seizures? 28. Thyroid disease?

4. Eye trouble or vision problems? 29. Other endocrine disease?

5. Ear problems or difficulty hearing?

30. Heavy menstrual bleeding?

6. Hay fever or other allergies? 31. Anemia/ hematological disorder?

7. Dental problems? 32. Easy bruising or bleeding?

8. Other ear, nose or throat problems?

33. Blood clots?

9. Wheezing or asthma? 34. Arthritis/ joint pains/swelling?

10. Shortness of breath on exertion? 35. Other connective tissue disease?

11. Chronic cough? 36. Joint or bone deformity/fracture?

12. Coughing up blood? 37. Back pain; wear a back brace?

13. Tuberculosis or (+) Tb skin test? 38. Difficulty walking?

14. Pain or pressure in your chest? 39. Eczema or atopic dermatitis?

15. Palpitations or pounding heart? 40. Other rashes?

16. Heart murmur? 41. Any other skin diseases?

17. Other heart problems? 42. Cancer?

18. High or low blood pressure? 43. Any immune system disorder?

19. Frequent indigestion/heartburn? 44. Chronic steroid treatment?

20. Stomach or intestinal problems? 45. Other immunosuppressive drugs?

21. Hepatitis or liver disease? 46. Nerve injury or paralysis?

22. Rupture or hernia? 47. A sleep disorder?

23. Rectal bleeding or discharge? 48. Easy fatigability?

24. Frequent urination? 49. Depression or crying spells?

25. Kidney stones? 50. Other psychiatric problems?

Give details of any “yes” answers above and comment on the current status of symptoms.

List and describe any other medical problem, symptom or concern not addressed above.

For women only: Are you currently pregnant? No Yes Date of last menstrual period: _____________

Please read and sign the following statement. If you feel you need additional information or have any questions regarding the medical risks of deployment or questions regarding the medical clearance process, please ask the CDC Occupational Health Clinic medical staff.

Deployment on a CDC/ATSDR response team could involve physical and emotional stressors and hazards, including but not limited to:

• rapid deployment to any location upon short notice

• deployment lengths lasting weeks to months

• separation from family and friends

• personal security issues

• sleep deprivation, time zone changes and irregular sleep schedules

• irregular quality, availability and variety of meals

• exposures to extremes of climate and altitude

• limited availability of immediate medical care

• lack of refrigeration or electricity for medications, medical supplies or equipment

• increased physical demands related to prolonged standing, walking, or exertion

• routine use of personal protective equipment such as respirators and protective clothing

• possible exposure to infectious organisms, chemical or radiologic agents

• risk related to allergy, adverse events or side effects from medications, vaccines or other required pharmaceutical interventions

• for pregnant women, possible risk to a developing fetus

• lifting and moving containers, equipment and boxes (approximately 40-50 lbs, and often repetitively)

• insect bites / stings

• loud noises (machinery and aircraft)

I have read the above medical questionnaire and statements. I have answered all questions accurately and to the best of my knowledge. I realize that further information or testing may be needed from my private physician or other sources to clarify my fitness for this duty. I know of no condition which would impair my ability to function fully on a CDC response team now or for the following year.

Employee Signature__________________________________ Date______________________

For employee’s personal physician (if necessary):

I have evaluated this person and, based on the items listed above, I find him or her to be ABLE/ UNABLE (please circle one) to meet the physical and mental requirements for deployment team participation.

Provider Name Date

Provider Signature Phone Number

REQUIRED TESTS FOR DEPLOYMENT:

nl abn EKG (if 50 years of age or older) nl abn SPIROMETRY (with respirator clearance OSHA form only) nl abn PULSE OX

DETAILED RESULTS OF ALL ABOVE TESTS WILL BE ATTACHED TO MEDICAL

RECORD

Medical Clearance Physical Exam Form

TO BE COMPLETED BY PROVIDER:

Height:_________

Weight:_________

Pulse:__________

BP:__________/__________

Pulse Ox:

Color Vision:

Passed Failed

Distant vision:

R 20/___ L 20/___ Corrected? Yes No

CLINICAL EVALUATION

Check each item as indicated.

Enter ‘NE’ if not evaluated

Normal

Abnormal

Notes or Other Comments

1. Skin

2. Head and neck including thyroid

3. Ear, nose and throat

4. Lymph nodes

5. Eyes including fundoscopic exam

6. Lungs and chest wall

7. Heart

8. Abdomen

9. Genitalia (if indicated)

10. Vascular system

11. Extremities and spine

12. Neurological

13. Psychiatric (specify any significant cognitive, mood or behavioral observations)

SUMMARY OF PROVIDER’S FINDINGS ON HISTORY AND EXAM

RECOMMENDATIONS FOR FURTHER EVALUATION

(attach additional page if necessary)

PROVIDER NAME & ADDRESS:

CDC Occupational Health Clinic 1600 Clifton Rd. Mail Stop A29 Atlanta, GA 30333

PROVIDER PHONE: 404-639-3385

FAX: 404-639-3166

E-MAIL ADDRESS: @cdc.gov

PROVIDER SIGNATURE DATE

Medical Clearance Provider Statement

I have examined:

I have reviewed with this patient the potential physical and emotional stressors and hazards present while serving as a member of a CDC Response Team. Based upon this patient’s medical history and physical exam, it is my recommendation that:

Yes No This individual appears mentally and physically capable of deployment on the following CDC Response Team(s):

[ ] Deployment

This individual has a medical condition which potentially limits his or her ability to safely participate as a member of a CDC Response Team.

Name of certifying provider (print): _________________________________________

Signature of certifying provider: ___________________________________________

Date: ______________________