PWS Attachment 14 Maintenance Personnel Annual Physical Exam Form.pdf

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. #

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

Visit for: Maintenance Personnel Pre-employment Physical Exam Form

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

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

3. Have any medications changed since your last exam

4. Have you ever had a major illness or injury

5. Have you ever had a hospitalization or surgery

6. Have you ever had cancer

7. Have you ever had a back injury

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

9. Have you ever smoked

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

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

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

13. Medication allergies

14. Any reproductive health concerns

15. Abnormal pregnancy outcome during present employment

16. Blood diseases (anemia, abnormal bleeding or clotting, etc)

17. Allergies (asthma, hay fever, eczema)

18. Skin disease, rash, erosion, ulcer, eczema, pigmentation abnormality or other skin abnormality

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

20. Treatment with steroids, immunosupressive or cancer (cytotoxic) drugs

21. Shortness of breath

22. Headache, dizziness, light headedness, weakness

23. Weight loss

24. Change or loss of vision in either eye

25. Cataracts

26. Eye irritation or blurred vision

27. Eye injury

28. Perforation of nasal septum

29. Ringing in the ear (tinnitus)

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

Medical History (continued)

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

31. Change or loss in hearing

32. Difficulty hearing conversations, people

33. Recreational or non-occupational exposure to loud noise

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

35. Repeated episodes of loss of or near loss of consciousness

36. Chest pain

37. Frequent pain or tightness in your chest

38. Coughing up blood (hemoptysis)

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

40. Chronic abdominal pain, vomiting, other GI symptoms

41. Liver disease

42. Injury with heavy bleeding in last year

43. Blood in stool

44. Seizures or fits

45. Kidney disease

46. Kidney stones

47. Problems with urination or blood in urine

48. Prostate gland problems

49. Protein in urine

50. Current pregnancy (females only)

51. Impotence or sexual dysfunction

52. Infertility or miscarriage (self or spouse)

53. Numbness, tingling, or weakness in hands or feet

54. Unexplained fatigue

55. Thyroid disease (including heat or cold intolerance)

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

57. Sleep disorder, breathing pauses while sleeping, sleep apnea, loud snoring, insomnia, daytime sleepiness

58. Depression, difficulty concentrating, excessive anxiety

59. Personality or behavior change

60. Bone problems (including broken bones)

61. Muscle or joint problems, rheumatism, or arthritis

62. Difficulty breathing while fitting or using a respirator

63. Musculoskeletal problems

64. Exposure to lead

65. Exposure to chromium or chromic acid

66. Exposure to excessive noise

67. Eye injury (occupational)

68. Exposure to skin irritants

69. Exposure to respiratory irritants

70. Exposure to solvents (MEK, PERC, TCE, toluene, etc.)

71. Exposure to cadmium

72. Are you exposed to airborne beryllium at work?

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

Medical History (continued)

73. Does your skin come into contact with beryllium at work?

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) SERVICE (USN / USMC / OTHER)

Studies and Immunizations

Chemistry:

Cadmium (CdB)

BUN

Creatinine

AST

Lead, whole blood

ZPP

Urine:

Urine Ph

Urine specific gravity

Urine urobilinogen

Urine protein

Urine glucose

Urine ketones

Urine blood

Urine RBCs

Urine WBCs

Urine Cadmium (CdU)

Urine Beta 2 microglobulin

Ensure urine specific gravity is >= 1.008 and pH is >= 5.5

Urine microscopic

Blood counts:

RBC

WBC

HGB

MCV

MCH

MCHC

HCT

Platelets

RBC

Morphology (Peripheral

Smear)

Immunizations:

Seasonal Influenza

Tdap one time, with subsequent Td every 10 years

Other studies or comments:

Other studies or comments:

Chest X-ray (PA)Audiogram Results

Spirometry

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

Comments

Comments on Studies, Immunizations, and Vision:

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

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

Physical Examination WNL Other (describe)

Head

Eyes

Ears (tympanic membranes)

Nose

Mucous membranes

Gums (e.g., lead lines)

Teeth (accelerated decay or loss)

Throat

Cardiovascular system

Respiratory system

Abdomen

Kidneys

Prostate palpation or other at-least-as-effective diagnostic test(s) for males over 40 years old

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

Central nervous system

Peripheral nervous system (strength, sensation, DTRs)

Comments on Physical Exam findings:

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

Assessment

Surveillance Examinations No abnormalities from occupational exposure

Abnormalities from occupational exposure, limitations as noted below Pending

METAL FUMES (602)

LEAD (INORGANIC) (161)

BERYLLIUM (121)

NOISE (503)

CADMIUM (CURRENT EXPOSURE) (124)

Disposition and Follow-up

Released from Occupational Health Clinic

Follow-up with PCM for

Return for follow-up exams:

Other disposition:

Discussed results of exam with employee

Physician’s or provider’s written opinion letter

Physician’s written opinion to the worker (only if General Industry)

Limitations and comments:

Provider Signature & Stamp: ______________________________ Date:__________