PWS Attachment 13 Chronological Record Police Security Pre employment Physical.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:

POLICE/SECURITY GUARD (Pre-employment 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 a major illness or injury Y N

5. Have you ever had a hospitalization or surgery Y N

6. Have you ever had cancer Y N

7. Have you ever had a back injury Y N

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

9. Have you ever smoked Y N

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

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

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

13. Medication allergies Y N

14. Any reproductive health concerns Y N

15. Shortness of breath Y N

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

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

18. Problems with night vision Y N

19. Change or loss in hearing Y N

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

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

22. Epilepsy or seizures Y N

23. Problems with balance or coordination Y N

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

25. Thyroid disease (including heat or cold intolerance) Y N

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

27. Mental or emotional illness Y N

28. Sleep disorder, breathing pauses while sleeping, sleep apnea, loud snoring, insomnia, daytime sleepiness Y N

29. Depression, difficulty concentrating, excessive anxiety Y N

30. Personality or behavior change Y N

31. Exposure to potentially infectious body fluids 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) Comments on Medical History:

MEDICAL FACILITY DEPARTMENT/SERVICE RECORDS MAINTAINED AT

PATIENT'S IDENTIFICATION:

LAST NAME (FIRST NAME, MIDDLE INITIAL)

DATE

Chemistry:

Cholesterol, total

LDL

HDL

Triglycerides

Other studies or comments:

Urine:

Urine Ph

Urine specific gravity

Urine urobilinogen

Urine protein

Urine glucose

Urine ketones

Urine blood

Urine RBCs

Urine WBCs

Other studies or comments:

Immunizations:

Hepatitis B vaccine #1

Hepatitis B vaccine #2

Hepatitis B vaccine #3

Hepatitis B titer

Td (Tdap once)

Seasonal Influenza Other studies or comments:

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

Color vision Pass Fail

Ishihara - # of plates

Other: ________________________

MEDICAL FACILITY DEPARTMENT/SERVICE RECORDS MAINTAINED AT

PATIENT'S IDENTIFICATION:

Spirometry, required for baseline/pre-employment exam

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

Audiogram Results Electrocardiogram

LAST NAME (FIRST NAME, MIDDLE INITIAL)

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)

DATE

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

Vital Signs

Physical Examination

Overall physical fitness

Metabolic disturbance (fever, tachycardia)

Eyes

Gaze (muscle balance, nystagmus)

Ears (tympanic membranes)

Nose

Throat

Thyroid

Cardiovascular system

Respiratory system Back & musculoskeletal system Skin (malignant & pre malignant conditions)

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:

2nd BP (taken at least 15 minutes apart): ___________________ Average BP: _____________________

LAST NAME (FIRST NAME, MIDDLE INITIAL)

DATE

Assessment Blood & body fluid precautions knowledge adequate

Certification Examinations Qualified Not Qualified Pending

POLICE/SECURITY WORKER (714)

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: POLICE/SECURITY WORKER 1 year .

Other disposition:

Discussed results of exam with employee

Limitations and comments:

Department of the Army police officers and security guards must be medically cleared to take a physical ability test (PAT). The PAT consists of one aerobic and one strength event. Candidates must be able to complete both primary events. Please evaluate and indicate whether the candidate is medically cleared to participate in the events below:

Primary Events: 1.5 mile run in 17:30 minutes 19 push-ups in 2 minutes

Medically cleared to participate in 1.5 mile run and 19 pushups

Temporarily disqualified due to a medical condition but is expected to be medically cleared at a later date

Not medically cleared to participate and is not expected to be medically cleared in the future

LAST NAME (FIRST NAME, MIDDLE INITIAL)

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

Comments:

1. Is your work exposure history current, and is surveillance/PPE consistent with
Comments on Medical History:
Comments on Studies, Immunizations, and Vision:
Occupation:
Agency:
Code:
Work Location:
Work Supervisor:
Duty tel:
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:
Chemistry Cholesterol total LDL HDL Triglycerides Other studies or comments:
Cholesterol total:
Urine Ph:
Immunizations Hepatitis B vaccine 1 Hepatitis B vaccine 2 Hepatitis B vaccine 3 Hepatitis B titer Td Tdap once Other studies or comments:
Hepatitis B vaccine 1:
LDL:
Urine specific gravity:
Hepatitis B vaccine 2:
HDL:
Urine urobilinogen:
Hepatitis B vaccine 3:
Triglycerides:
Urine protein:
Hepatitis B titer:
Urine glucose:
Td Tdap once:
Urine ketones:
Urine blood:
Urine RBCs:
Urine WBCs:
Audiogram DD 22152216:
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:
undefined_2:
Color vision:
Ishihara of plates:
PassIshihara of plates:
FailIshihara of plates:
Other:
PassOther:
FailOther:
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:
Other describe:
undefined_3:
undefined_4:
undefined_5:
undefined_6:
undefined_7:
undefined_8:
undefined_9:
undefined_10:
undefined_11:
undefined_12:
undefined_13:
undefined_14:
undefined_15:
undefined_16:
undefined_17:
undefined_18:
undefined_19:
undefined_20:
undefined_21:
undefined_22:
undefined_23:
undefined_24:
undefined_25:
undefined_26:
undefined_27:
undefined_28:
1_7:
2_7:
3:
4:
5:
6:
7:
8:
9:
10:
11:
12:
13:
14:
undefined_29:
undefined_30:
undefined_31:
2nd BP taken at least 15 minutes apart:
Average BP:
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:
Blood body fluid precautions knowledge adequate:
undefined_32: Off
Certification Examinations:
Qualified:
undefined_33:
Not Qualified:
undefined_34:
Pending:
undefined_35:
Released from Occupational Health Clinic: Off
Followup with PCM for: Off
Return for followup exams POLICESECURITY WORKER: Off
Other disposition: Off
Discussed results of exam with employee: Off
1 year:
undefined_36:
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:
Text4:
Text6:
Check Box11: Off
Check Box12: Off
Check Box13: Off
Text10:
Date11_af_date:
Date12_af_date:
Date13_af_date:
Date14_af_date:
Date15_af_date:
Date16_af_date:

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