PWS Attachment 08 Firefighter Termination Exam Form.pdf

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Attached to
United States Army Reserve Command (USARC) Physical Exams
Solicitation number
W81K04-22-R-0018
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MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE

DATE

PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal or regulatory investigations or prosecutions. The Social Security Number, authorized by Public Law 93-579 Section 7 (b) and Executive Order 9397, is used as a unique identifier to distinguish between employees with the same names and birth dates and to ensure that each individual's record in the system is complete and accurate and the information is properly attributed.

Employee info:

Occupation Agency Code Work Location Work Supervisor Duty tel. #

Visit for:

FIREFIGHTER TERMINATION PHYSICAL

Medical History

1. Is your work exposure history current and is surveillance/PPE consistent with exposures/occupations Y N

2. Has anything about your health status changed since your last examination Y N

3. Have any medications changed since your last exam Y N

4. Have you ever had cancer Y N

5. Have you ever had a back injury Y N

6. Do you drink 6 or more drinks per week (beer, wine, liquor) Y N

7. Have you ever smoked Y N

8. Do you currently smoke or use smokeless tobacco or electronic cigarettes ( packs/day) Y N

9. Heart disease, high blood pressure, stroke or circulation problems Y N

10. Current medication use (prescription or over the counter) Y N

11. Blood diseases (anemia, abnormal bleeding or clotting, etc) Y N

12. Allergies (asthma, hay fever, eczema) Y N

13. Have you ever been evaluated for latex allergy Y N

14. Skin disease, rash, erosion, ulcer, eczema, pigmentation abnormality or other skin abnormality Y N

15. Heat injury (heat cramps, exhaustion, stroke) Y N

16. Peripheral vascular disease, or do your fingers or toes turn color or become painful in cold weather Y N

17. Hepatitis or jaundice Y N

18. Lung or respiratory disease (ex: COPD, bronchitis, pneumonia, asbestosis, silicosis, pneumothorax / collapsed lung) Y N

19. Wheezing Y N

20. Tuberculosis or PPD Converter Y N

21. Shortness of breath Y N

22. Headache, dizziness, light headedness, weakness Y N

23. Cold injury (frostbite, chill, trench foot, hypothermia) Y N

24. Head injury Y N

25. Use of eye glasses Y N

26. Change or loss of vision in either eye Y N

27. Difficulty with distinguishing colors Y N

28. Inability or reduced ability to smell Y N

29. Ringing in the ear (tinnitus) Y N

30. Any injury to your ears (including ruptured ear drum) Y N

31. Change or loss in hearing Y N

32. A need to wear a hearing aid Y N

33. Any other hearing or ear problem Y N

MEDICAL FACILITY DEPARTMENT/SERVICE RECORDS MAINTAINED AT

PATIENT'S IDENTIFICATION:

LAST NAME (FIRST NAME, MIDDLE INITIAL)

GENDER (M/F) DATE OF BIRTH (DD-MMM-YYYY)

STATUS (AD / RESERVE / CIV) DOD ID#

DATE

Medical History (continued)

34. Difficulty hearing conversations, people Y N

35. Recreational or non-occupational exposure to loud noise Y N

36. Chest pain, angina, heart attack, irregular heart beat (arrhythmia), palpitation, or other heart problem Y N

37. Repeated episodes of loss of or near loss of consciousness Y N

38. Swelling in legs or feet (not caused by walking) Y N

39. Cough, other than with colds, flu or allergies Y N

40. Chronic abdominal pain, vomiting, other GI symptoms Y N

41. Kidney disease Y N

42. Current pregnancy (females only) Y N

43. Epilepsy or seizures Y N

44. Problems with balance or coordination Y N

45. Numbness, tingling, or weakness in hands or feet Y N

46. Diabetes (sugar disease) or other endocrine disorder (thyroid, parathyroid, pituitary, adrenal gland) Y N

47. Mental or emotional illness Y N

48. Depression, difficulty concentrating, excessive anxiety Y N

49. Claustrophobia Y N

50. Muscle or joint problems, rheumatism, or arthritis Y N

51. Any other muscle or skeletal problem that may interfere with using a respirator Y N

52. Latex allergy or sensitivity Y N

53. Do you have any symptoms which you think may be related to hazards you are exposed to at work Y N

54. Prior respirator use Y N

55. Any problems with prior respirator use Y N

56. Exposure to potentially infectious body fluids Y N

Comments on Medical History:

MEDICAL FACILITY DEPARTMENT/SERVICE RECORDS MAINTAINED AT

PATIENT'S IDENTIFICATION:

LAST NAME (FIRST NAME, MIDDLE INITIAL)

GENDER (M/F) DATE OF BIRTH (DD-MMM-YYYY)

STATUS (AD / RESERVE / CIV) DOD ID

Is the Firefighter part of the Dive team? Yes No

Does employee report any injuries related to work during time of employment? No Yes Comments:

DATE

Studies and Immunizations

Vision DISTANCE NEAR

Right Left Both Right Left Both

With Correction 20 / 20 / 20 / 20 / 20 / 20 /

Without Correction 20 / 20 / 20 / 20 / 20 / 20 /

Visual fields Right Left

Horizontal (lateral) field of vision, degrees

MEDICAL FACILITY DEPARTMENT/SERVICE RECORDS MAINTAINED AT

PATIENT'S IDENTIFICATION:

Spirometry

FVC FEV1 FEV1/FVC Rate of FEV1 Decline (% or mL/yr

Comments

Chest X-ray (PA & LAT) Audiogram Results

Electrocardiogram

Chemistry:

Fasting blood glucose

BUN

Creatinine

HgbA1C (if Diabetic)

Urinary microalbumin (diabetics only)

Cholesterol, total

LDL

Percent LDL

HDL

Triglycerides

AST

ALT

Bilirubin, Total

Alkaline phosphatase

Total protein

GGT

Albumin

Other studies or comments:

Urine:

Urine Ph

Urine specific gravity

Urine urobilinogen

Urine protein

Urine glucose

Urine ketones

Urine blood

Other studies or comments:

Blood counts:

RBC

WBC

HGB

MCV

MCH

MCHC

HCT

Neutrophils

Lymphocytes

Monocytes

Eosinophils

Basophils

Platelets

Other studies or comments:

Immunizations:

Hepatitis A vaccine or titer unless immunity or 2 doses vaccine documented

Hepatitis B vaccine or titer unless completed series documented

Tdap once with subsequent Td every 10 years.

MMR vaccine unless 2 doses vaccine documented or positive titer

Varicella vaccine unless 2 doses vaccine documented or positive titer Seasonal Influenza Vaccination (offer to worker)

Tuberculosis Quantiferon Gold test

Other studies or comments:

LAST NAME (FIRST NAME, MIDDLE INITIAL)

GENDER (M/F) DATE OF BIRTH (DD-MMM-YYYY)

STATUS (AD / RESERVE / CIV) DOD ID

Non-divers: Baseline and every 5 years/ Divers: Baseline and every 3 years.

Non-divers: Baseline, 35y, 40y, and annually over 40y - Divers: Baseline and every year

(Baseline, Annually, and Termination Exams

DATE

Studies and Immunizations (continued)

Comments on Studies, Immunizations, and Vision:

MEDICAL FACILITY DEPARTMENT/SERVICE RECORDS MAINTAINED AT

PATIENT'S IDENTIFICATION:

LAST NAME (FIRST NAME, MIDDLE INITIAL)

STATUS (AD / RESERVE / CIV) DOD ID

DATE

Vital Signs

Physical Examination

Eyes

Ears (tympanic membranes)

Thyroid

Cardiovascular system

Respiratory system

Liver

Check for inguinal or femoral hernia

Back & musculoskeletal system

Skin (rash, erosion, ulcer, pigment, eczema, etc.)

Central nervous system

Peripheral nervous system (strength, sensation, DTRs)

Psychiatric (especially emotional stability)

WNL Other (describe)

MEDICAL FACILITY DEPARTMENT/SERVICE RECORDS MAINTAINED AT

PATIENT'S IDENTIFICATION:

Comments on Physical Exam findings:

Blood pressure: Pulse: Respiratory rate: Temperature: Height: Weight:

LAST NAME (FIRST NAME, MIDDLE INITIAL)

STATUS (AD / RESERVE / CIV) DOD ID

DATE

Assessment

Blood & body fluid precautions knowledge adequate

Certification Examinations

FIREFIGHTER

Disposition and Follow-up

MEDICAL FACILITY DEPARTMENT/SERVICE RECORDS MAINTAINED AT

PATIENT'S IDENTIFICATION:

Released from Occupational Health Clinic

Follow-up with PCM for

Return for follow-up exams: FIREFIGHTER

Other disposition:

Discussed results of exam with employee

Physician’s or provider’s written opinion

Limitations and comments:

Provider Signature & Stamp: Date:

LAST NAME (FIRST NAME, MIDDLE INITIAL)

GENDER (M/F) DATE OF BIRTH (DD-MMM-YYYY)

STATUS (AD / RESERVE / CIV) DOD ID

Corrective Lenses recommended for: _________________________________________________ Return to see audiologist on: ________________________________________________________ Return visit in ___________ months

Medically qualified without restrictions Medically qualified with restriction(s) listed below Restrictions, recommendations and/or other comments:

Medically qualified for unlimited respirator usage (SCBA or neg. pressure)

Medically disqualified for respirator usage

Medically qualified for wearing N-95 respirator/ surgical mask

Medically qualified for respirator usage with following restriction(s):

Occupation:
Agency:
Code:
Work Location:
Work Supervisor:
Duty tel:
8 Do you currently smoke or use smokeless tobacco or electronic cigarettes:
MEDICAL FACILITY:
DEPARTMENTSERVICE:
RECORDS MAINTAINED AT:
LAST NAME FIRST NAME MIDDLE INITIAL:
GENDER MF:
DATE OF BIRTHDDMMMYYYY:
STATUS AD RESERVE CIV:
DOD ID:
Comments on Medical History:
MEDICAL FACILITY_2:
DEPARTMENTSERVICE_2:
RECORDS MAINTAINED AT_2:
LAST NAME FIRST NAME MIDDLE INITIAL_2:
GENDER MF_2:
DATE OF BIRTHDDMMMYYYY_2:
STATUS AD RESERVE CIV_2:
DOD ID_2:
Fasting blood glucose:
RBC:
Immunizations Hepatitis A vaccine or titer unless immunity or 2 doses vaccine documented Hepatitis B vaccine or titer unless immunity documented Td every 10 years or Tdap once Seasonal Influenza Vaccination offer to worker Tuberculosis skinblood test Other studies or comments:
titer unless immunity or:
WBC:
Creatinine:
HGB:
titer unless immunity:
HgbA1C if Diabetic:
MCV:
undefined:
MCH:
Cholesterol total:
Td every 10 years or:
MCHC:
HCT:
Neutrophils:
Row1:
Vaccination offer to:
Lymphocytes:
Row2:
Tuberculosis skinblood:
Monocytes:
Triglycerides:
Eosinophils:
AST:
Basophils:
ALT:
Platelets:
Row1_2:
Row2_2:
GGT:
Albumin:
Audiogram DD 22152216:
Chest Xray PA LAT:
Electrocardiogram:
FVC:
FEV1:
FEV1FVC:
Rate of FEV1 Decline or mLyr:
Comments:
VisionRow1:
20:
20_2:
20_3:
20_4:
20_5:
20_6:
1:
2:
20_7:
1_2:
2_2:
20_8:
1_3:
2_3:
20_9:
1_4:
2_4:
20_10:
1_5:
2_5:
20_11:
1_6:
2_6:
20_12:
Visual fields:
Horizontal lateral field of vision degrees:
undefined_2:
undefined_3:
MEDICAL FACILITY_3:
DEPARTMENTSERVICE_3:
RECORDS MAINTAINED AT_3:
LAST NAME FIRST NAME MIDDLE INITIAL_3:
GENDER MF_3:
DATE OF BIRTHDDMMMYYYY_3:
STATUS AD RESERVE CIV_3:
DOD ID_3:
Comments on Studies Immunizations and Vision:
MEDICAL FACILITY_4:
DEPARTMENTSERVICE_4:
RECORDS MAINTAINED AT_4:
LAST NAME FIRST NAME MIDDLE INITIAL_4:
GENDER MF_4:
DATE OF BIRTHDDMMMYYYY_4:
STATUS AD RESERVE CIV_4:
DOD ID_4:
Blood pressure:
Pulse:
Respiratory rate:
Temperature:
Height:
Weight:
WNL:
undefined_4:
undefined_5:
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Other describe 1:
Other describe 2:
Other describe 3:
Other describe 4:
Other describe 5:
Other describe 6:
Other describe 7:
Other describe 8:
Other describe 9:
Other describe 10:
Other describe 11:
Other describe 12:
undefined_26:
Comments on Physical Exam findings:
MEDICAL FACILITY_5:
DEPARTMENTSERVICE_5:
RECORDS MAINTAINED AT_5:
LAST NAME FIRST NAME MIDDLE INITIAL_5:
GENDER MF_5:
DATE OF BIRTHDDMMMYYYY_5:
STATUS AD RESERVE CIV_5:
DOD ID_5:
undefined_27: Off
Released from Occupational Health Clinic: Off
Followup with PCM for: Off
Return for followup exams FIREFIGHTER COMPREHENSIVE: Off
Other disposition: Off
Discussed results of exam with employee: Off
Physicians or providers written opinion: Off
undefined_31:
1 year:
Corrective Lenses recommended for:
Return visit in:
Date:
MEDICAL FACILITY_6:
DEPARTMENTSERVICE_6:
RECORDS MAINTAINED AT_6:
LAST NAME FIRST NAME MIDDLE INITIAL_6:
GENDER MF_6:
DATE OF BIRTHDDMMMYYYY_6:
STATUS AD RESERVE CIV_6:
DOD ID_6:
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