Exhibit_17_Record_Layout_PHA_DD3024_201604_v1.xlsx

XLSX spreadsheet 61 KB Posted Nov 29, 2017

Attached to: Special Notice-Amendment 0009 Federal contract opportunity
Solicitation number: W15QKN-17-R-1042
Issued by: Department of the Army Materiel Command Contracting Command Picatinny Arsenal

About this file

Written by GovTribe AI · Dec 30, 2023

This is a presolicitation notice for a Reserve Health Readiness Program III contract to provide health readiness services to Reserve and National Guard members. The services include immunizations, physical examinations, assessments, dental care, laboratory services, and occupational health. The Defense Health Agency will award a single firm-fixed-price and cost reimbursement contract for five years to support all military service reserve components throughout the U.S. and its territories. Interested parties should monitor the Federal Business Opportunities website for the anticipated solicitation number W15QKN-17-R-1042 to be issued on or around September 30, 2017.

From the source

Exhibit 17

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Other files for this federal contract opportunity

Other files attached to Special Notice-Amendment 0009, newest first.
File	Type	Posted
RHRP-3_Attachment_0007_Technical_Scenarios_Rev_2_May_2018.pdf	PDF	May 29, 2018
W15QKN-18-R-1000_Conformed_V05-29-18.pdf	PDF	May 29, 2018
RHRP-3_Attachment_0007_Technical_Scenario_Locations_2_May_2018.xlsx	XLSX spreadsheet	May 29, 2018
Attch_0011_Quality_Assurance_Surveillance_Plan_1-24-18.pdf	PDF	Feb 15, 2018
Industry_Questions_2-15-2018.pdf	PDF	Feb 15, 2018
Conform_-_W15QKN-18-R-1000.docx	DOCX document	Feb 15, 2018
Attachment_0007_Technical_Scenarios_24_Jan_2018.pdf	PDF	Feb 15, 2018
RHRP-3_Amend_0004_Exhibits_7-11.zip	ZIP file	Jan 30, 2018
RHRP-3_Amend_0004_Exhibits_14.zip	ZIP file	Jan 30, 2018
RHRP-3_Amend_0004_Attachments.zip	ZIP file	Jan 30, 2018
W15QKN-18-R-1000-0004_(Released).pdf	PDF	Jan 30, 2018
RHRP-3_PWS_-_7_Dec_clean.pdf	PDF	Dec 8, 2017
RHRP-3_Preproposal_Conference_Attendee_List.pdf	PDF	Dec 8, 2017
Exhibit_14d_RHRP-3_Post_Event_Report_4.4.2.3.xls	XLS spreadsheet	Nov 29, 2017
B001_Weekly_and_Monthly_and_Quarterly_-_RHRP-3.pdf	PDF	Nov 29, 2017
Exhibit_14n_CSS_Poor_Rating_Monthly_Resolution_Completed__Detail_4.4.4.5.xlsx	XLSX spreadsheet	Nov 29, 2017
Attachment_-0004_Price_Matrix_Cost-Price_Vol_III-9-30-17-dl.xlsx	XLSX spreadsheet	Nov 29, 2017
Exhibit_14o_USAR_Monthly_Dental_Summary_4.4.4.23.xlsx	XLSX spreadsheet	Nov 29, 2017
Exhibit_14q_Dental_Report_Card_4.4.5.1.xls	XLS spreadsheet	Nov 29, 2017
Attachment_0006_basis_of_award-9-30-17-draft.docx	DOCX document	Nov 29, 2017
Exhibit_3_NDA_contractor.docx	DOCX document	Nov 29, 2017
Exhibit_14l_HIV_Specimen_Stats__4.4.4.6.xlsx	XLSX spreadsheet	Nov 29, 2017
Attch_0011_Quality_Assurance_Surveillance_Plan.doc	DOC document	Nov 29, 2017
Attachment_9-SFFL_4_Short_Term_EAL_Form_2017.pdf	PDF	Nov 29, 2017
Exhibit_13_Checklist_and_Certification_for_Safeguarding_Unclassified_DoD_Info_Nov_2014.docx	DOCX document	Nov 29, 2017
Attachment_0005_Proposal_Submission.docx	DOCX document	Nov 29, 2017
Exhibit_14_-_Report__Matrix.xlsx	XLSX spreadsheet	Nov 29, 2017
Exhibit_14i_Speed_of_Data_Entry_into_SC_Database_4.4.4.3.xlsx	XLSX spreadsheet	Nov 29, 2017
Exhibit_14p_Detail_Report_with_Dental_Event_Reclassification_4.4.4.25.xlsx	XLSX spreadsheet	Nov 29, 2017
Exhibit_2c_DD_Form_3024_OFFICIAL_LOCKED.pdf	PDF	Nov 29, 2017
Exhibit_14s_Group_Event_POC_Survey_Results_4.4.4.15.xlsx	XLSX spreadsheet	Nov 29, 2017
Exhibit_14f_Avoidable_Costs_YTD__4.4.4.20.xlsx	XLSX spreadsheet	Nov 29, 2017
PWS_-_22_Nov_2017.pdf	PDF	Nov 22, 2017
B002 Financial Reports.pdf	PDF	Oct 25, 2017
W15QKN-18-R-1000_Draft.docx	DOCX document	Oct 25, 2017
Exhibit 14i Speed of Data Entry into SC Database 4_4_4_3.xlsx	XLSX spreadsheet	Oct 25, 2017
B005 Group Events.pdf	PDF	Oct 25, 2017
Attachment 0010 Pre Award Survey of Prospective Contractor Accounting Systems Checklist.pdf	PDF	Oct 25, 2017
D003 Transition Plan Phase Out.pdf	PDF	Oct 25, 2017
Attachment 0008 Preproposal Conference Intent to Participate Form R1.pdf	PDF	Oct 25, 2017
Attachment 0009 SFFL5.pdf	PDF	Oct 25, 2017
Attachment 0004 Price Matrix Cost-Price Vol III 9-30-17-dl.xlsx	XLSX spreadsheet	Oct 25, 2017
Exhibit 14g PDHRA and MHA Monthly Activity Management Report 4_4_4_22.xlsx	XLSX spreadsheet	Oct 25, 2017
Exhibit 14h RHRP_Event Planning and Forecast 4.4.3.4.xlsx	XLSX spreadsheet	Oct 25, 2017
Exhibit 14b Invoice Reports 4_4_4_2.xlsx	XLSX spreadsheet	Oct 25, 2017
Attachment 0007 Technical Scenarios.docx	DOCX document	Oct 25, 2017
Exhibit 13 Checklist and Certification for Safeguarding Unclassified DoD.docx	DOCX document	Oct 25, 2017
D001 Quality Assurance Plan.pdf	PDF	Oct 25, 2017
Exhibit 14e InClinic Services By Service Date 4_4_4_18.xlsx	XLSX spreadsheet	Oct 25, 2017
Attachment 0001 PWS List of Exhibits 09-20-17.doc	DOC document	Oct 25, 2017

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PHA_20150315

ORDER	QUESTION	FIELD NAME	LENGTH	START POS	END POS	DESCRIPTION	VALUES
1		FORM_TYPE	3	1	3	Type of Form	PHA
2		FORM_VERSION	15	4	18	DoD Form Number	DD3024_201604
3	SMI1	LNAME	25	19	43	Last Name	Text Field
4	SMI2	FNAME	25	44	68	First Name	Text Field
5	SMI3	MI	25	69	93	Middle Initial / Name	Text Field
6	SMI4	D_EVENT	8	94	101	Today's Date (Date on Form)	YYYYMMDD Format
7	SMI5	DOB	8	102	109	Date of Birth	YYYYMMDD Format
8	SMI6	AGE	2	110	111	Age	99
9	SMI7	SSN	9	112	120	Social Security Number	999999999
10	SMI8	SEX	1	121	121	Sex	M=Male, F=Female
11	SMI9	DODID	10	122	131	DoD ID number (formerly EDIPI)	9999999999
12	SMI10	SERVICE	1	132	132	Service Branch	F=AIR FORCE, A=ARMY, N=NAVY, M=MARINE CORPS, C=COAST GUARD, P=USPHS, D=Other Defense Agency
13	SMI10	SERVICE_OTHER	50	133	182	Other Defense Agency	Text Field
14	SMI11	STATUS	3	183	185	Status	G = Gaurdsmen, R = Reservist, AGR = AGR/FTS, A = Active Duty
15	SMI12	GRADE	3	186	188	Pay Grade	E01=E1, E02=E2, E03=E3, E04=E4, E05=E5, E06=E6, E07=E7, E08=E8, E09=E9, O01=O1, O02=O2, O03=O3, O04=O4, O05=O5, O06=O6, O07=O7, O08=O8, O09=O9, O10=O10, W01=W1, W02=W2, W03=W3, W04=W4, W05=W5
16	SMI13	UNIT_NAME	75	189	263	Unit Name	Text Field
17	SMI14	UNIT_LOC	75	264	338	Duty Station/Location	Text Field
18	SMI15	UIC	10	339	348	UIC/RUC	Text Field
19	SMI16	PHA_FIRST	1	349	349	First Periodic Health Assessment (PHA)	Y=Yes, N=No, U=Don't know
20	SMI17	SEC_MES	1	350	350	Enrolled in Secure Messaging System with Provider	Y=Yes, N=No, U=Don't know
21	SMI18	CONTACT_PREF	1	351	351	Preferred Method of Contact	1=DSN Phone, 2=Other Phone(s), 3=Email(s), 4=RelayHealth, 5=Address
22	SMI18	DSN	20	352	371	DSN Phone	Text Field
23	SMI18	PHONE_OTHER	20	372	391	Other Phone	Text Field
24	SMI18	EMAIL	75	392	466	Email	Text Field
25	SMI18	ADDR	60	467	526	Address	Text Field
26	SMI18	STATE	2	527	528	State	Text Field
27	SMI18	ZIP	10	529	538	ZIP Code	Text Field
28	SMI19	POC_NAME	50	539	588	POC Name	Text Field
29	SMI19	POC_PHONE1	20	589	608	POC Phone #1	Text Field
30	SMI19	POC_PHONE2	20	609	628	POC Phone #2	Text Field
31	SMI19	POC_EMAIL	75	629	703	POC Email	Text Field
32	SMI19	POC_ADDR	60	704	763	POC Address	Text Field
33	SMI19	POC_STATE	2	764	765	POC STATE	Text Field
34	SMI19	POC_ZIP	10	766	775	POC ZIP Code	Text Field
35	DEP1	DEP_PAST	1	776	776	Total number of deployments within the PAST 5 YEARS	N=Never, 0=0, 1=1, 2=2, 3=3, 4=4, 5=5 or more
36	DEP2	DEP_PRIMARY	15	777	791	Primary country of last deployment	Text Field
37	DEP3	D_DEPART	8	792	799	Date departed theater	YYYYMMDD Format
38	DEP4	DEP_FUTURE	1	800	800	Going to deploy in the next 120 days	Y=Yes, N=No
39	OCC1a	MOS	10	801	810	Military occupational code	Text Field
40	OCC1b	DUTIES	200	811	1010	Typical military job duties	Text Field
41	OCC2	EXAM	1	1011	1011	Military specialty requires an operational physical exam	Y=Yes, N=No
42	OCC3	ENROLL	1	1012	1012	Currently enrolled in a medical surveillance / occupational health program	Y=Yes, N=No, U=Don't know
43	DLC1	DLC_CHEST	1	1013	1013	During the past 12 months, bothered by: Chest pain/angina	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
44	DLC1	DLC_CHF	1	1014	1014	During the past 12 months, bothered by: Congestive heart failure	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
45	DLC1	DLC_HEART	1	1015	1015	During the past 12 months, bothered by: Abnormal heart beat	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
46	DLC1	DLC_HTN	1	1016	1016	During the past 12 months, bothered by: High Blood Pressure	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
47	DLC1	DLC_ASTHMA	1	1017	1017	During the past 12 months, bothered by: Asthma	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
48	DLC1	DLC_LUNG	1	1018	1018	During the past 12 months, bothered by: Other Lung problems	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
49	DLC1	DLC_TB	1	1019	1019	During the past 12 months, bothered by: Tuberculosis	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
50	DLC1	DLC_CANCER	1	1020	1020	During the past 12 months, bothered by: Cancer or history of cancer	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
51	DLC1	DLC_DIABETES	1	1021	1021	During the past 12 months, bothered by: Diabetes	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
52	DLC1	DLC_VISION	1	1022	1022	During the past 12 months, bothered by: Change in vision that impacts duty performance	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
53	DLC1	DLC_TBI	1	1023	1023	During the past 12 months, bothered by: Head injury/Traumatic Brain Injury (TBI)	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
54	DLC1	DLC_DIZZY	1	1024	1024	During the past 12 months, bothered by: Periods of dizziness, fainting, or loss of consciousness	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
55	DLC1	DLC_NEURO	1	1025	1025	During the past 12 months, bothered by: Neurological problems	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
56	DLC1	DLC_NOISES	1	1026	1026	During the past 12 months, bothered by: Noises in head or ears	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
57	DLC1	DLC_HEARING	1	1027	1027	During the past 12 months, bothered by: Change in hearing that impacts duty performance	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
58	DLC1	DLC_CHOL	1	1028	1028	During the past 12 months, bothered by: High or bad cholesterol	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
59	DLC2	DLC_WHEEZING	1	1029	1029	During the past 12 months, bothered by: Wheezing, shortness of breath, or difficulty breathing	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
60	DLC2	DLC_RASH	1	1030	1030	During the past 12 months, bothered by: New skin condition	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
61	DLC2	DLC_MUSCLE	1	1031	1031	During the past 12 months, bothered by: Recurring muscle, joint, or low back pain	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
62	DLC2	DLC_HEADACHE	1	1032	1032	During the past 12 months, bothered by: Recurring headaches/migraines	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
63	DLC2	DLC_STOMACH	1	1033	1033	During the past 12 months, bothered by: Stomach problems (for example: ulcer, reflux)	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
64	DLC2	DLC_KIDNEY	1	1034	1034	During the past 12 months, bothered by: Kidney problem	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
65	DLC2	DLC_LIVER	1	1035	1035	During the past 12 months, bothered by: Liver problems	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
66	DLC2	DLC_BLOOD	1	1036	1036	During the past 12 months, bothered by: Blood problems	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
67	DLC2	DLC_IMMUNE	1	1037	1037	During the past 12 months, bothered by: Immune system problems	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
68	DLC2	DLC_TOOTH	1	1038	1038	During the past 12 months, bothered by: Tooth or gum problems/pain	0=No, 1=Yes no care, 2=Yes but not under treatment, 3=Yes and under treatment
69	DLC3	PROF_CHEST	1	1039	1039	Currently on Profile for: Chest pain/angina	Y=Yes, N=No
70	DLC3	PROF_CHF	1	1040	1040	Currently on Profile for: Congestive heart failure	Y=Yes, N=No
71	DLC3	PROF_HEART	1	1041	1041	Currently on Profile for: Abnormal heart beat	Y=Yes, N=No
72	DLC3	PROF_HTN	1	1042	1042	Currently on Profile for: High Blood Pressure	Y=Yes, N=No
73	DLC3	PROF_ASTHMA	1	1043	1043	Currently on Profile for: Asthma	Y=Yes, N=No
74	DLC3	PROF_WHEEZING	1	1044	1044	Currently on Profile for: Wheezing, shortness of breath, or difficulty breathing	Y=Yes, N=No
75	DLC3	PROF_LUNG	1	1045	1045	Currently on Profile for: Other Lung problems	Y=Yes, N=No
76	DLC3	PROF_TB	1	1046	1046	Currently on Profile for: Tuberculosis	Y=Yes, N=No
77	DLC3	PROF_CANCER	1	1047	1047	Currently on Profile for: Cancer or history of cancer	Y=Yes, N=No
78	DLC3	PROF_RASH	1	1048	1048	Currently on Profile for: New skin condition	Y=Yes, N=No
79	DLC3	PROF_DIABETES	1	1049	1049	Currently on Profile for: Diabetes	Y=Yes, N=No
80	DLC3	PROF_MUSCLE	1	1050	1050	Currently on Profile for: Chronic muscle, joint, or low back pain	Y=Yes, N=No
81	DLC3	PROF_VISION	1	1051	1051	Currently on Profile for: Change in vision that impacts duty performance	Y=Yes, N=No
82	DLC3	PROF_HEADACHE	1	1052	1052	Currently on Profile for: Chronic headaches/migraines	Y=Yes, N=No
83	DLC3	PROF_TBI	1	1053	1053	Currently on Profile for: Head injury/Traumatic Brain Injury (TBI)	Y=Yes, N=No
84	DLC3	PROF_DIZZY	1	1054	1054	Currently on Profile for: Periods of dizziness, fainting, or loss of consciousness	Y=Yes, N=No
85	DLC3	PROF_NEURO	1	1055	1055	Currently on Profile for: Neurological problems	Y=Yes, N=No
86	DLC3	PROF_NOISES	1	1056	1056	Currently on Profile for: Noises in head or ears	Y=Yes, N=No
87	DLC3	PROF_HEARING	1	1057	1057	Currently on Profile for: Change in hearing that impacts duty performance	Y=Yes, N=No
88	DLC3	PROF_CHOL	1	1058	1058	Currently on Profile for: High or bad cholesterol	Y=Yes, N=No
89	DLC3	PROF_STOMACH	1	1059	1059	Currently on Profile for: Stomach problems (for example: ulcer, reflux)	Y=Yes, N=No
90	DLC3	PROF_KIDNEY	1	1060	1060	Currently on Profile for: Kidney problem	Y=Yes, N=No
91	DLC3	PROF_LIVER	1	1061	1061	Currently on Profile for: Liver problems	Y=Yes, N=No
92	DLC3	PROF_BLOOD	1	1062	1062	Currently on Profile for: Blood problems	Y=Yes, N=No
93	DLC3	PROF_IMMUNE	1	1063	1063	Currently on Profile for: Immune system problems	Y=Yes, N=No
94	DLC3	PROF_TOOTH	1	1064	1064	Currently on Profile for: Tooth or gum problems/pain	Y=Yes, N=No
95	DLC4	SURGERY	1	1065	1065	Surgery since last PHA	Y=Yes, N=No
96	DLC5a	SURG_COND1	100	1066	1165	Condition for which you had surgery	Text Field
97	DLC5b	SURG_COND2	100	1166	1265	Condition for which you had surgery	Text Field
98	DLC5c	SURG_COND3	100	1266	1365	Condition for which you had surgery	Text Field
99	DLC5a1	SURG_TYPE1	100	1366	1465	Type of surgery	Text Field
100	DLC5b1	SURG_TYPE2	100	1466	1565	Type of surgery	Text Field
101	DLC5c1	SURG_TYPE3	100	1566	1665	Type of surgery	Text Field
102	DLC6a	SURG_REC	1	1666	1666	Health care provider recommended surgery	Y=Yes, N=No
103	DLC6b	SURG_REC_COND	100	1667	1766	Condition for which surgery was recommended	Text Field
104	DLC7a	SPECIAL	1	1767	1767	Require special accommodations	Y=Yes, N=No
105	DLC7b	SPECIAL_TEXT	100	1768	1867	What are your requirements?	Text Field
106	DLC8a	WAIVER	1	1868	1868	Waiver/profile for any part of Physical Fitness test	Y=Yes, N=No
107	DLC8b	WAIVER_BODY	1	1869	1869	Waiver: Body Composition Analysis	1=Checked, 0=Not Checked
108	DLC8b	WAIVER_CARDIO	1	1870	1870	Waiver: Cardio Event	1=Checked, 0=Not Checked
109	DLC8b	WAIVER_SITUPS	1	1871	1871	Waiver: Crunches / Sit-Ups	1=Checked, 0=Not Checked
110	DLC8b	WAIVER_PUSHUPS	1	1872	1872	Waiver: Push-Ups	1=Checked, 0=Not Checked
111	DLC8b	WAIVER_PULLUPS	1	1873	1873	Waiver: Pull-Ups or Flexed Arm Hang	1=Checked, 0=Not Checked
112	DLC8b	WAIVER_OTHER	1	1874	1874	Waiver: Other	1=Checked, 0=Not Checked
113	DLC8b	WAIVER_OTHER_TEXT	50	1875	1924	Waiver: Other Text	Text Field
114	DLC9a	EQUIP_PROB	1	1925	1925	Problem wearing protective equipment	Y=Yes, N=No, X=Never had to wear
115	DLC9b	EQUIP_PROB_TEXT	100	1926	2025	Protective equipment comments	Text Field
116	DLC10a	IMM_EXEMPT	1	2026	2026	told by a health care provider SHOULD NOT receive a vaccine/immunization	Y=Yes, N=No
117	DLC10b	IMM_EXEMPT_LIST	50	2027	2076	Which vaccines/immunizations	Text Field
118	DLC10c	IMM_EXEMPT_WHY	50	2077	2126	Why? (for example: pregnancy, illness, previous reaction)	Text Field
119	DLC10d	IMM_EXEMPT_TEXT	50	2127	2176	What was the reaction, if any?	Text Field
120	DLC11a	PERM_PROFILE	1	2177	2177	Permanent Profile	Y=Yes, N=No, U=Don't know
121	DLC11b	PERM_PROFILE_TEXT	50	2178	2227	Permanent Profile Comments	Text Field
122	DLC12a	TEMP_PROFILE	1	2228	2228	Temporary Profile	Y=Yes, N=No, M=Yes but feels ready for full duty
123	DLC12b	TEMP_PROFILE_TEXT	50	2229	2278	Temporary Profile Comments	Text Field
124	DLC13	TEMP_PROFILE_TIMES	2	2279	2280	During the PAST 2 YEARS, how many times have you been placed on a temporary profile or on limited duty	99
125	IMR1	ALLERGIES	1	2281	2281	Do you have any allergies (not including seasonal or pet allergies)?	Y=Yes, N=No, U=Don't know
126	IMR2	ALL_TAPE	1	2282	2282	Allergy to: Tape	1=Checked, 0=Not Checked
127	IMR2	ALL_ASPIRIN	1	2283	2283	Allergy to: Aspirin	1=Checked, 0=Not Checked
128	IMR2	ALL_BEES	1	2284	2284	Allergy to: Bees	1=Checked, 0=Not Checked
129	IMR2	ALL_CODEINE	1	2285	2285	Allergy to: Codeine	1=Checked, 0=Not Checked
130	IMR2	ALL_EGGS	1	2286	2286	Allergy to: Eggs	1=Checked, 0=Not Checked
131	IMR2	ALL_IODINE	1	2287	2287	Allergy to: Iodine	1=Checked, 0=Not Checked
132	IMR2	ALL_LATEX	1	2288	2288	Allergy to: Latex	1=Checked, 0=Not Checked
133	IMR2	ALL_MILK	1	2289	2289	Allergy to: Milk	1=Checked, 0=Not Checked
134	IMR2	ALL_NICKEL	1	2290	2290	Allergy to: Nickel	1=Checked, 0=Not Checked
135	IMR2	ALL_NUTS	1	2291	2291	Allergy to: Nuts	1=Checked, 0=Not Checked
136	IMR2	ALL_PENICILLIN	1	2292	2292	Allergy to: Penicillin	1=Checked, 0=Not Checked
137	IMR2	ALL_SHELLFISH	1	2293	2293	Allergy to: Shellfish	1=Checked, 0=Not Checked
138	IMR2	ALL_SULFA	1	2294	2294	Allergy to: Sulfa	1=Checked, 0=Not Checked
139	IMR2	ALL_VACCINES	1	2295	2295	Allergy to: Vaccines	1=Checked, 0=Not Checked
140	IMR2	ALL_OTHER	1	2296	2296	Allergy to: Other	1=Checked, 0=Not Checked
141	IMR2	ALL_OTHER_TEXT	50	2297	2346	Specify Other Allergy	Text Field
142	IMR3	MEDICAL_DOG_TAG	1	2347	2347	red medical warning "dog" tags	1=Yes (current), 2=Yes (not current), 3=No (need one), 4=No
143	IMR4	GLASSES	1	2348	2348	Do you wear corrective lenses (glasses or contacts)?	Y=Yes, N=No
144	IMR5	GLASSES_NUM	1	2349	2349	How many pairs of glasses do you have?	0=0, 1=1, 2=2 or more
145	IMR6	INSERTS	1	2350	2350	Do you have gas mask inserts?	Y=Yes, N=No
146	MHA1a	STRESSORS	1	2351	2351	Over the PAST MONTH, what major life stressors have you experienced that are a cause of significant concern or make it difficult for you to do your work, take care of things at home, or get along with other people (for example, serious conflicts with others, relationship problems, or a legal, disciplinary or financial problem)?	0=None, 1=Yes response
147	MHA1a	STRESSORS_TEXT	100	2352	2451	Please list and explain	Text Field
148	MHA1b	STRESSORS_HELP	1	2452	2452	Are you currently in treatment or getting professional help for this concern?	Y=Yes, N=No
149	MHA2	CARE_MENTAL	1	2453	2453	In the PAST YEAR, did you receive care for any mental health condition or concern such as, but not limited to post traumatic stress disorder (PTSD), depression, anxiety disorder, alcohol abuse or substance abuse?	Y=Yes, N=No
150	MHA2	CARE_MENTAL_TEXT	100	2454	2553	If yes, please explain	Text Field
151	MHA3	CURRENT_MEDS	1	2554	2554	What prescription or over-the-counter medications (including herbals/supplements) for sleep, pain, combat stress or a mental health problem are you CURRENTLY taking?	0=None, 1=Yes response
152	MHA3	CURRENT_MEDS_TEXT	100	2555	2654	If yes, please list.	Text Field
153	MHA4a	ETOH_OFTEN	1	2655	2655	How often do you have a drink containing alcohol?	0=Never, 1=Monthly, 2=2-4 times a month, 3=2-3 times per week, 4=4 or more times a week
154	MHA4b	ETOH_DAY	1	2656	2656	How many drinks containing alcohol do you have on a typical day when you are drinking?	1=1 or 2, 2=3 or 4, 3=5 or 6, 4=7 to 9, 5=10 or more
155	MHA4c	ETOH_BINGE	1	2657	2657	How often do you have six or more drinks on one occasion?	0=Never, 1=Less than monthly, 2=monthly, 3=weekly, 4=Daily or almost daily
156	MHA5a	NIGHTMARES	1	2658	2658	Have you ever had any experience that was so frightening, horrible, or upsetting that, in the PAST MONTH, you: Have had nightmares about it or thought about it when you did not want to?	Y=Yes, N=No
157	MHA5b	AVOID_SITUATIONS	1	2659	2659	Have you ever had any experience that was so frightening, horrible, or upsetting that, in the PAST MONTH, you: Tried hard not to think about it or went out of your way to avoid situations that remind you of it?	Y=Yes, N=No
158	MHA5c	ON_GUARD	1	2660	2660	Have you ever had any experience that was so frightening, horrible, or upsetting that, in the PAST MONTH, you: Were constantly on guard, watchful or easily startled?	Y=Yes, N=No
159	MHA5d	DETACHED	1	2661	2661	Have you ever had any experience that was so frightening, horrible, or upsetting that, in the PAST MONTH, you: Felt numb or detached from others, activities, or your surroundings?	Y=Yes, N=No
160	MHA5e	MEMORIES	1	2662	2662	Have you been bothered by that problem in the PAST MONTH. Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?	0=Not at all, 1=A little bit, 2=Moderately, 3=Quite a bit, 4=Extremely
161	MHA5f	DREAMS	1	2663	2663	Have you been bothered by that problem in the PAST MONTH. Repeated, disturbing dreams of a stressful experience from the past?	0=Not at all, 1=A little bit, 2=Moderately, 3=Quite a bit, 4=Extremely
162	MHA5g	RELIVING	1	2664	2664	Have you been bothered by that problem in the PAST MONTH. Suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it)?	0=Not at all, 1=A little bit, 2=Moderately, 3=Quite a bit, 4=Extremely
163	MHA5h	UPSET	1	2665	2665	Have you been bothered by that problem in the PAST MONTH. Feeling very upset when something reminded you of a stressful experience from the past?	0=Not at all, 1=A little bit, 2=Moderately, 3=Quite a bit, 4=Extremely
164	MHA5i	PHYS_REACTION	1	2666	2666	Have you been bothered by that problem in the PAST MONTH. Having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of a stressful experience from the past?	0=Not at all, 1=A little bit, 2=Moderately, 3=Quite a bit, 4=Extremely
165	MHA5j	AVOID_THINK	1	2667	2667	Have you been bothered by that problem in the PAST MONTH. Avoid thinking about or talking about a stressful experience from the past or avoid having feelings related to it?	0=Not at all, 1=A little bit, 2=Moderately, 3=Quite a bit, 4=Extremely
166	MHA5k	AVOID_ACTIVITIES	1	2668	2668	Have you been bothered by that problem in the PAST MONTH. Avoid activities or situations because they remind you of a stressful experience from the past?	0=Not at all, 1=A little bit, 2=Moderately, 3=Quite a bit, 4=Extremely
167	MHA5l	TROUBLE_MEMORY	1	2669	2669	Have you been bothered by that problem in the PAST MONTH. Trouble remembering important parts of a stressful experience from the past?	0=Not at all, 1=A little bit, 2=Moderately, 3=Quite a bit, 4=Extremely
168	MHA5m	DISINTEREST	1	2670	2670	Have you been bothered by that problem in the PAST MONTH. Loss of interest in things that you used to enjoy?	0=Not at all, 1=A little bit, 2=Moderately, 3=Quite a bit, 4=Extremely
169	MHA5n	DISTANT	1	2671	2671	Have you been bothered by that problem in the PAST MONTH. Feeling distant or cut off from other people?	0=Not at all, 1=A little bit, 2=Moderately, 3=Quite a bit, 4=Extremely
170	MHA5o	NUMB	1	2672	2672	Have you been bothered by that problem in the PAST MONTH. Feeling emotionally numb or being unable to have loving feelings for those close to you?	0=Not at all, 1=A little bit, 2=Moderately, 3=Quite a bit, 4=Extremely
171	MHA5p	DOOM	1	2673	2673	Have you been bothered by that problem in the PAST MONTH. Feeling as if your future will somehow be cut short?	0=Not at all, 1=A little bit, 2=Moderately, 3=Quite a bit, 4=Extremely
172	MHA5q	INSOMNIA	1	2674	2674	Have you been bothered by that problem in the PAST MONTH. Trouble falling or staying asleep?	0=Not at all, 1=A little bit, 2=Moderately, 3=Quite a bit, 4=Extremely
173	MHA5r	ANGRY_OUTBURSTS	1	2675	2675	Have you been bothered by that problem in the PAST MONTH. Feeling irritable or having angry outbursts?	0=Not at all, 1=A little bit, 2=Moderately, 3=Quite a bit, 4=Extremely
174	MHA5s	CONCENTRATE	1	2676	2676	Have you been bothered by that problem in the PAST MONTH. Having difficulty concentrating?	0=Not at all, 1=A little bit, 2=Moderately, 3=Quite a bit, 4=Extremely
175	MHA5t	WATCHFUL	1	2677	2677	Have you been bothered by that problem in the PAST MONTH. Being “super alert” or watchful, on guard?	0=Not at all, 1=A little bit, 2=Moderately, 3=Quite a bit, 4=Extremely
176	MHA5u	ALERT	1	2678	2678	Have you been bothered by that problem in the PAST MONTH. Feeling jumpy or easily startled?	0=Not at all, 1=A little bit, 2=Moderately, 3=Quite a bit, 4=Extremely
177	MHA5v	LIFE_DIFFICULT	1	2679	2679	How difficult have these problems (11e. through 11u) made it for you to do your work, take care of things at home, or get along with other people?	0=Not difficult at all, 1=Somewhat difficult, 2=Very difficult, 3=Extremely difficult
178	MHA6a	WEEKS_LITTLE_INTEREST	1	2680	2680	Over the LAST 2 WEEKS, how often have you been bothered by the following problems? Little interest or pleasure in doing things	0=Not at all, 1=Few or several days, 3=More than half the days, 4=Nearly every day
179	MHA6b	WEEKS_DEPRESSED	1	2681	2681	Over the LAST 2 WEEKS, how often have you been bothered by the following problems? Feeling down, depressed, or hopeless	0=Not at all, 1=Few or several days, 3=More than half the days, 4=Nearly every day
180	MHA6c	WEEKS_SLEEP	1	2682	2682	Over the LAST 2 WEEKS, how often have you been bothered by the following problems? Trouble falling/staying asleep, sleep too much.	0=Not at all, 1=Few or several days, 3=More than half the days, 4=Nearly every day
181	MHA6d	WEEKS_TIRED	1	2683	2683	Over the LAST 2 WEEKS, how often have you been bothered by the following problems? Feeling tired or having little energy	0=Not at all, 1=Few or several days, 3=More than half the days, 4=Nearly every day
182	MHA6e	WEEKS_APPETITE	1	2684	2684	Over the LAST 2 WEEKS, how often have you been bothered by the following problems? Poor appetite or overeating.	0=Not at all, 1=Few or several days, 3=More than half the days, 4=Nearly every day
183	MHA6f	WEEKS_FAILURE	1	2685	2685	Over the LAST 2 WEEKS, how often have you been bothered by the following problems? Feeling bad about yourself – or that you are a failure or have let yourself or your family down.	0=Not at all, 1=Few or several days, 3=More than half the days, 4=Nearly every day
184	MHA6g	WEEKS_CONCENTRATE	1	2686	2686	Over the LAST 2 WEEKS, how often have you been bothered by the following problems? Trouble concentrating on things, such as reading the newspaper or watching television.	0=Not at all, 1=Few or several days, 3=More than half the days, 4=Nearly every day
185	MHA6h	WEEKS_LETHARGIC_JUMPY	1	2687	2687	Over the LAST 2 WEEKS, how often have you been bothered by the following problems? Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety that you have been moving around a lot more than usual.	0=Not at all, 1=Few or several days, 3=More than half the days, 4=Nearly every day
186	MHA6i	WEEKS_PROBLEMS	1	2688	2688	How difficult have these problems (12a.through12h.) made it for you to do your work, take care of things at home, or get along with other people?	0=Not difficult at all, 1=Somewhat difficult, 2=Very difficult, 3=Extremely difficult
187	MHA7	REQ_PROVIDER	1	2689	2689	Would you like to schedule an appointment with a health care provider to discuss any health concern(s)?	Y=Yes, N=No
188	MHA8	REQ_STRESS	1	2690	2690	Are you interested in receiving information or assistance for a stress, emotional or alcohol concern?	Y=Yes, N=No
189	MHA9	REQ_FAMILY	1	2691	2691	Are you interested in receiving assistance for a family or relationship concern?	Y=Yes, N=No
190	MHA10	REQ_CHAPLAIN	1	2692	2692	Would you like to schedule a visit with a chaplain or a community support counselor?	Y=Yes, N=No
191	LIF1	HEALTH_ASSESSMENT	1	2693	2693	Overall, how would you rate your health during the PAST MONTH?	E=Excellent, V=Very Good, G=Good, F=Fair, P=Poor
192	LIF2	FAM_HX_CANCER	1	2694	2694	Family History of Cancer	1=Checked, 0=Not Checked
193	LIF2	FAM_HX_HEART	1	2695	2695	Family History of Heart Problems	1=Checked, 0=Not Checked
194	LIF2	FAM_HX_DIABETES	1	2696	2696	Family History of Diabetes	1=Checked, 0=Not Checked
195	LIF2	FAM_HX_NONE	1	2697	2697	No known or Unknown Family History	1=Checked, 0=Not Checked
196	LIF3	FAM_HX_BREAST	6	2698	2703	Family History of Breast Cancer	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 001001=hx in GM and sister)
197	LIF3	FAM_HX_COLON	6	2704	2709	Family History of Colon Cancer	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 001001=hx in GM and sister)
198	LIF3	FAM_HX_OVARIAN	6	2710	2715	Family History of Ovarian Cancer	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 001001=hx in GM and sister)
199	LIF3	FAM_HX_PROSTATE	6	2716	2721	Family History of Prostate Cancer	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 001001=hx in GM and sister)
200	LIF3	FAM_HX_OTH_CA1	6	2722	2727	Family History of Other#1 Cancer	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 001001=hx in GM and sister)
201	LIF3	FAM_HX_OTH_CA2	6	2728	2733	Family History of Other#2 Cancer	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 001001=hx in GM and sister)
202	LIF3	FAM_HX_OTH_CA3	6	2734	2739	Family History of Other#3 Cancer	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 001001=hx in GM and sister)
203	LIF3	FAM_HX_OTH_CA1_TEXT	50	2740	2789	Specify Family Hx Other1 Cancer	Text Field
204	LIF3	FAM_HX_OTH_CA2_TEXT	50	2790	2839	Specify Family Hx Other2 Cancer	Text Field
205	LIF3	FAM_HX_OTH_CA3_TEXT	50	2840	2889	Specify Family Hx Other3 Cancer	Text Field
206	LIF3	FAM_HX_UNK_CA	6	2890	2895	Family History of Unknown Cancer	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 001001=hx in GM and sister)
207	LIF4	FAM_HX_HTN	6	2896	2901	Family History of High Blood Pressure	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 000110=hx in GF and brother)
208	LIF4	FAM_HX_MI	6	2902	2907	Family History of Heart Attack	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 000110=hx in GF and brother)
209	LIF4	FAM_HX_BEAT	6	2908	2913	Family History of Arrhythmia	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 000110=hx in GF and brother)
210	LIF4	FAM_HX_DEATH	6	2914	2919	Family History of Cardiac Death	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 000110=hx in GF and brother)
211	LIF4	FAM_HX_OTH_HR1	6	2920	2925	Family History of Other#1 Heart	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 000110=hx in GF and brother)
212	LIF4	FAM_HX_OTH_HR2	6	2926	2931	Family History of Other#2 Heart	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 000110=hx in GF and brother)
213	LIF4	FAM_HX_OTH_HR3	6	2932	2937	Family History of Other#3 Heart	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 000110=hx in GF and brother)
214	LIF4	FAM_HX_OTH_HR1_TEXT	50	2938	2987	Specify Family Hx Other1 Heart	Text Field
215	LIF4	FAM_HX_OTH_HR2_TEXT	50	2988	3037	Specify Family Hx Other2 Heart	Text Field
216	LIF4	FAM_HX_OTH_HR3_TEXT	50	3038	3087	Specify Family Hx Other3 Heart	Text Field
217	LIF4	FAM_HX_UNK_HR	6	3088	3093	Family History of Unknown Cardiac	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 000110=hx in GF and brother)
218	LIF5	FAM_HX_TYPE1	6	3094	3099	Family History of Type I Diabetes	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 010000=hx in father)
219	LIF5	FAM_HX_TYPE2	6	3100	3105	Family History of Type II Diabetes	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 010000=hx in father)
220	LIF5	FAM_HX_UNK_DM	6	3106	3111	Family History of Unknown Diabetes	1=checked; 1st position=Mother, 2=Father, 3=GM, 4=GF, 5=Brother, 6=Sister (ex. 010000=hx in father)
221	LIF6	VIGOROUS_DAYS	1	3112	3112	Vigorous activity days per week	9 (0-7 only)
222	LIF6	VIGOROUS_MINS	3	3113	3115	Vigorous activity minutes per day	999
223	LIF7	LIGHT_DAYS	1	3116	3116	Light/Mod activity days per week	9 (0-7 only)
224	LIF7	LIGHT_MINS	3	3117	3119	Light/Mod activity minutes per day	999
225	LIF8	STRENGTH_DAYS	1	3120	3120	Strengthen activity days per week	9 (0-7 only)
226	LIF9	SUP_PROTEIN	1	3121	3121	Products taken in last 12 months: Protein Sup.	1=Checked, 0=Not Checked
227	LIF9	SUP_MUSCLE	1	3122	3122	Products taken in last 12 months: Muscle building	1=Checked, 0=Not Checked
228	LIF9	SUP_PERFORM	1	3123	3123	Products taken in last 12 months: Performance	1=Checked, 0=Not Checked
229	LIF9	SUP_ENERGY	1	3124	3124	Products taken in last 12 months: Energy shots	1=Checked, 0=Not Checked
230	LIF9	SUP_WEIGHT	1	3125	3125	Products taken in last 12 months: Weight loss	1=Checked, 0=Not Checked
231	LIF9	SUP_HERBAL	1	3126	3126	Products taken in last 12 months: Herbal Sup.	1=Checked, 0=Not Checked
232	LIF9	SUP_MULTI	1	3127	3127	Products taken in last 12 months: Multi-Vitamins	1=Checked, 0=Not Checked
233	LIF9	SUP_VITAMINS	1	3128	3128	Products taken in last 12 months: Vitamins	1=Checked, 0=Not Checked
234	LIF9	SUP_OMEGA3	1	3129	3129	Products taken in last 12 months: Omega-3	1=Checked, 0=Not Checked
235	LIF9	SUP_JOINT	1	3130	3130	Products taken in last 12 months: Joint care	1=Checked, 0=Not Checked
236	LIF9	SUP_NONE	1	3131	3131	Products taken in last 12 months: None	1=Checked, 0=Not Checked
237	LIF10	SUP_PROTEIN_TIMES	1	3132	3132	How often taken in last 12 months: Protein Sup.	1=Less than once/mo, 2=once/mo, 3=once/wk, 4=every other day, 5=once/day, 6=two or more/day
238	LIF10	SUP_MUSCLE_TIMES	1	3133	3133	How often taken in last 12 months: Muscle building	1=Less than once/mo, 2=once/mo, 3=once/wk, 4=every other day, 5=once/day, 6=two or more/day
239	LIF10	SUP_PERFORM_TIMES	1	3134	3134	How often taken in last 12 months: Performance	1=Less than once/mo, 2=once/mo, 3=once/wk, 4=every other day, 5=once/day, 6=two or more/day
240	LIF10	SUP_ENERGY_TIMES	1	3135	3135	How often taken in last 12 months: Energy shots	1=Less than once/mo, 2=once/mo, 3=once/wk, 4=every other day, 5=once/day, 6=two or more/day
241	LIF10	SUP_WEIGHT_TIMES	1	3136	3136	How often taken in last 12 months: Weight loss	1=Less than once/mo, 2=once/mo, 3=once/wk, 4=every other day, 5=once/day, 6=two or more/day
242	LIF10	SUP_HERBAL_TIMES	1	3137	3137	How often taken in last 12 months: Herbal Sup.	1=Less than once/mo, 2=once/mo, 3=once/wk, 4=every other day, 5=once/day, 6=two or more/day
243	LIF10	SUP_MULTI_TIMES	1	3138	3138	How often taken in last 12 months: Multi-Vitamins	1=Less than once/mo, 2=once/mo, 3=once/wk, 4=every other day, 5=once/day, 6=two or more/day
244	LIF10	SUP_VITAMINS_TIMES	1	3139	3139	How often taken in last 12 months: Vitamins	1=Less than once/mo, 2=once/mo, 3=once/wk, 4=every other day, 5=once/day, 6=two or more/day
245	LIF10	SUP_OMEGA3_TIMES	1	3140	3140	How often taken in last 12 months: Omega-3	1=Less than once/mo, 2=once/mo, 3=once/wk, 4=every other day, 5=once/day, 6=two or more/day
246	LIF10	SUP_JOINT_TIMES	1	3141	3141	How often taken in last 12 months: Joint care	1=Less than once/mo, 2=once/mo, 3=once/wk, 4=every other day, 5=once/day, 6=two or more/day
247	LIF11	EAT_FRUITS	1	3142	3142	How often eaten in last 30 days: Fruits	1=Rarely, 2=one to two/wk, 3=three to six/wk, 4=one serving/day, 5=two to three/day, 6=four or more/day
248	LIF11	EAT_VEGS	1	3143	3143	How often eaten in last 30 days: Vegetables	1=Rarely, 2=one to two/wk, 3=three to six/wk, 4=one serving/day, 5=two to three/day, 6=four or more/day
249	LIF11	EAT_GRAINS	1	3144	3144	How often eaten in last 30 days: Whole Grains	1=Rarely, 2=one to two/wk, 3=three to six/wk, 4=one serving/day, 5=two to three/day, 6=four or more/day
250	LIF11	EAT_DAIRY	1	3145	3145	How often eaten in last 30 days: Dairy	1=Rarely, 2=one to two/wk, 3=three to six/wk, 4=one serving/day, 5=two to three/day, 6=four or more/day
251	LIF11	EAT_FISH	1	3146	3146	How often eaten in last 30 days: Fish	1=Rarely, 2=one to two/wk, 3=three to six/wk, 4=one serving/day, 5=two to three/day, 6=four or more/day
252	LIF11	EAT_PROTEIN	1	3147	3147	How often eaten in last 30 days: Lean Protein	1=Rarely, 2=one to two/wk, 3=three to six/wk, 4=one serving/day, 5=two to three/day, 6=four or more/day
253	LIF11	EAT_SUGAR	1	3148	3148	How often eaten in last 30 days: Sugar-sweetened Beverages	1=Rarely, 2=one to two/wk, 3=three to six/wk, 4=one serving/day, 5=two to three/day, 6=four or more/day
254	LIF12	CHOLESTEROL	1	3149	3149	Cholesterol checked within the PAST 5 YEARS	Y=Yes, N=No, U=Don't know
255	LIF13a	TOB_CIGS	1	3150	3150	Used once in last 30 days: Cigarettes	1=Checked, 0=Not Checked
256	LIF13a	TOB_CIGARS	1	3151	3151	Used once in last 30 days: Cigars	1=Checked, 0=Not Checked
257	LIF13a	TOB_CHEW	1	3152	3152	Used once in last 30 days: Chewing Tobacco	1=Checked, 0=Not Checked
258	LIF13a	TOB_E_CIGS	1	3153	3153	Used once in last 30 days: Electronic Cigarettes	1=Checked, 0=Not Checked
259	LIF13a	TOB_HOOK	1	3154	3154	Used once in last 30 days: Hookahs	1=Checked, 0=Not Checked
260	LIF13a	TOB_PIPE	1	3155	3155	Used once in last 30 days: Pipes	1=Checked, 0=Not Checked
261	LIF13a	TOB_SNUS	1	3156	3156	Used once in last 30 days: Snus	1=Checked, 0=Not Checked
262	LIF13a	TOB_DISS	1	3157	3157	Used once in last 30 days: Dissolvable tobacco	1=Checked, 0=Not Checked
263	LIF13a	TOB_BIDIS	1	3158	3158	Used once in last 30 days: Bidis	1=Checked, 0=Not Checked
264	LIF13a	TOB_OTHER	1	3159	3159	Used once in last 30 days: Other	1=Checked, 0=Not Checked
265	LIF13a	TOB_OTHER_TEXT	25	3160	3184	Tobacco Other: text	Text Field
266	LIF13a	TOB_NONE	1	3185	3185	Used once in last 30 days: No Tobacco	1=Checked, 0=Not Checked
267	LIF13b	TOB_LONG	1	3186	3186	How long have you been using tobacco products?	1=less than one yr, 2=one tofive yrs, 3=six to ten yrs, 4 =ten to fifteen yrs, 5=greater than fifteen yrs
268	LIF13c	TOB_PACKS	1	3187	3187	How many packs per day do you smoke?	1=less than .5 pk, 2=.5 to 1 pk, 3=1.5 to 2 pks, 4 =2.5 to 3 pks, 5=greater than 3 pks
269	LIF14	TOB_QUIT	1	3188	3188	Interested in quitting tobacco?	1-Yes, wants referral, 2=Yes, no referral, 3=No
270	LIF15	TOB_PAST	1	3189	3189	Past use of tobacco?	Y=Used tobacco, N=Never used
271	LIF15	TOB_PAST_YEAR	4	3190	3193	Year quit using tobacco	YYYY Format
272	LIF16	TOB_SMOKE	1	3194	3194	Regularly exposed to secondhand smoke	Y=Yes, N=No
273	LIF17	SLEEP	1	3195	3195	Hours of sleep did you get on most days?	1=Less than 5 hours, 2=5 to less than 7 hours, 3=7 to 9 hours, 4=More than 9 hours
274	LIF18	SLEEP_POOR	1	3196	3196	Felt impaired or unable to adequately perform due to sleepiness in last 2 weeks	Y=Yes, N=No
275	LIF19	WEIGHT_CHANGE	1	3197	3197	unexplained weight loss or gain in the LAST YEAR	Y=Yes, N=No
276	LIF20	STI_RISK	1	3198	3198	Risk of STI/STD	1=At risk, 2=Not at risk
277	LIF21	STI_TEST	1	3199	3199	syphilis, chlamydia, and gonorrhea test	Y=Yes, N=No
278	LIF22	PREG_NA	1	3200	3200	Method to avoid pregnancy: N/A	1=Checked, 0=Not Checked
279	LIF22	PREG_NONE_TRYING	1	3201	3201	Method to avoid pregnancy: None, but trying to become pregnant	1=Checked, 0=Not Checked
280	LIF22	PREG_STERILIZATION	1	3202	3202	Method to avoid pregnancy: STERILIZATION	1=Checked, 0=Not Checked
281	LIF22	PREG_IUD	1	3203	3203	Method to avoid pregnancy: IUD	1=Checked, 0=Not Checked
282	LIF22	PREG_IMPLANT	1	3204	3204	Method to avoid pregnancy: IMPLANT	1=Checked, 0=Not Checked
283	LIF22	PREG_BCP	1	3205	3205	Method to avoid pregnancy: BCP's	1=Checked, 0=Not Checked
284	LIF22	PREG_CONDOM	1	3206	3206	Method to avoid pregnancy: CONDOM	1=Checked, 0=Not Checked
285	LIF22	PREG_WITHDRAWL	1	3207	3207	Method to avoid pregnancy: WITHDRAWL	1=Checked, 0=Not Checked
286	LIF22	PREG_RHYTHM	1	3208	3208	Method to avoid pregnancy: RHYTHM	1=Checked, 0=Not Checked
287	LIF22	PREG_DIAPHRAGM	1	3209	3209	Method to avoid pregnancy: DIAPHRAGM	1=Checked, 0=Not Checked
288	LIF22	PREG_PLANB	1	3210	3210	Method to avoid pregnancy: Emergency Contraception	1=Checked, 0=Not Checked
289	LIF22	PREG_NONE	1	3211	3211	Method to avoid pregnancy: NONE	1=Checked, 0=Not Checked
290	LIF22	PREG_OTHER	1	3212	3212	Method to avoid pregnancy: OTHER	1=Checked, 0=Not Checked
291	LIF22	PREG_OTHER_TEXT	25	3213	3237	Method to avoid pregnancy: OTHER text	Text Field
292	WOM1	WOM_PREG	1	3238	3238	Which of the following best describes you?	1=Currently or may be pregnant, 2=pregnant within 6 mos, 3=pregnant within 6-12 mos, 4=not pregnant
293	WOM2	WOM_HYST	1	3239	3239	Have you had a total hysterectomy?	Y=Yes, N=No
294	WOM3	WOM_POST	1	3240	3240	Postmenopausal and no longer experiencing menstrual cycles?	Y=Yes, N=No
295	WOM4	WOM_FOLIC	1	3241	3241	Are you currently taking folic acid or a vitamin containing folic acid?	Y=Yes, N=No, U=Don't know
296	WOM5	WOM_MENS	1	3242	3242	Do you have heavy and/or irregular menstrual cycles/pain or premenstrual syndrome?	1=Yes under treatment, 2=Yes ongoing, 3=No
297	WOM6	WOM_UTI	1	3243	3243	Do you have recurrent urinary tract infections (more than 3 in the past 12 months)?	1=Yes under treatment, 2=Yes ongoing, 3=No
298	WOM7	WOM_PAP	1	3244	3244	Have you had a Pap test (cervical cancer screening) within the PAST 3 YEARS?	Y=Yes, N=No, U=Don't know
299	WOM8	WOM_MAM	1	3245	3245	Have you had a mammogram within the PAST 2 YEARS?	Y=Yes, N=No
300	WOM9	WOM_STI	1	3246	3246	Have you had a chlamydia and/or gonorrhea test in the PAST 12 MONTHS?	Y=Yes, N=No
301	WOM9	WOM_DIABETES	1	3247	3247	Do you have a history of gestational diabetes?	Y=Yes, N=No
302	RES1	RES_ILLNESS	1	3248	3248	injury, illness, or disease which was incurred or aggravated while in a duty status within the PAST 12 MONTHS	Y=Yes, N=No
303	RES2	RES_LOD	1	3249	3249	pending a Line of Duty (LOD) for that injury, illness, or disease	1=Yes (initiated), 2=Yes (completed), 3=No
304	RES3	RES_LOD_TEXT1	25	3250	3274	specify LOD1 injury, illness, or disease	Text Field
305	RES3	RES_LOD_TEXT2	25	3275	3299	specify LOD2 injury, illness, or disease	Text Field
306	RES3	RES_LOD_TEXT3	25	3300	3324	specify LOD3 injury, illness, or disease	Text Field
307	RES3	RES_LOD_DATE1	6	3325	3330	Specify Year and Month when LOD1 condition began	YYYYMM Format
308	RES3	RES_LOD_DATE2	6	3331	3336	Specify Year and Month when LOD2 condition began	YYYYMM Format
309	RES3	RES_LOD_DATE3	6	3337	3342	Specify Year and Month when LOD3 condition began	YYYYMM Format
310	RES4	RES_INS_TRICARE	1	3343	3343	Covered under a health insurance policy: TRICARE	1=Checked, 0=Not Checked
311	RES4	RES_INS_OTHER	1	3344	3344	Covered under a health insurance policy: OTHER	1=Checked, 0=Not Checked
312	RES4	RES_INS_NONE	1	3345	3345	Covered under a health insurance policy: NONE	1=Checked, 0=Not Checked
313	RES5a	WORK_COMP	1	3346	3346	limitations related to a Workers’ Compensation	1=Yes, 2=No (never), 3=No (applied)
314	RES5b	WORK_COMP_TEXT	100	3347	3446	limitations related to a Workers’ Compensation: Text	Text Field
315	RES6	VA_DISABILITY	1	3447	3447	VA disability rating	1=No, 2=Yes, 3=Yes (pending), 4=Yes (denied)
316	RES7	VA_RATING	3	3448	3450	Enter total disability rating (%)	999 (1-100 only)
317	RES8	VA_RATING_DATE	6	3451	3456	Approximate date received disability rating?	YYYYMM Format
318	RES9	VA_DISABILITY_TYPE	50	3457	3506	Type of injury(s) or medical condition(s) basis of VA disability claim(s)?	Text Field
319	RES10	VA_DISABILITY_COND	100	3507	3606	physical or mental health limitations related to VA disability	Text Field
320	OTH1	PAIN_SCALE	2	3607	3608	Amount of pain over the PAST 24 HOURS.	99 (0-10 only)
321	OTH2	PAIN_TX	1	3609	3609	Are you receiving treatment for your pain?	Y=Yes, N=No
322	OTH3	OTH_MEDS	1	3610	3610	prescriptions or over-the-counter medications	0=None, 1=Medications
323	OTH3	OTH_MEDS_TEXT	100	3611	3710	List prescription or over-the-counter medications are you CURRENTLY taking	Text Field
324	OTH4	CIV_CARE	1	3711	3711	received care or treatment for any medical/mental health conditions from a civilian or non-military facility	Y=Yes, N=No
325	OTH5	CIV_CARE_TEXT	100	3712	3811	list the conditions treated	Text Field
326	OTH5	CIV_CARE_WHERE	100	3812	3911	list where the care was provided	Text Field
327	OTH6	ACKNOWLEGE	1	3912	3912	I acknowledge I am responsible to report medical (including mental health) and health issues that may affect my readiness to deploy or fitness to continue serving in an active status	1=Checked, 0=Not Checked
328	OTH7	HEALTH_CONCERNS	1	3913	3913	Concerned about any other health condition(s) not already addressed?	Y=Yes, N=No
329	OTH8	HEALTH_CONCERNS_TEXT	250	3914	4163	comment on these conditions and/or concerns.	Text Field
330	SEP1	SEPARATION	1	4164	4164	planning to separate or retire from Active Duty or Reserve military service	Y=Yes, N=No
331	RRI1	RR_LNAME	25	4165	4189	Reviewers Last Name	Text Field
332	RRI2	RR_FNAME	25	4190	4214	Reviewers First Name	Text Field
333	RRI3	RR_MNAME	25	4215	4239	Reviewers Middle Name	Text Field
334	RRI4	RR_SERVICE	1	4240	4240	Reviewer Service Branch	F=AIR FORCE, A=ARMY, N=NAVY, M=MARINE CORPS, C=COAST GUARD, P=USPHS, D=Other Defense Agency
335	RRI4	RR_SERVICE_OTHER	25	4241	4265	Other Defense Agency	Text Field
336	RRI5	RR_STATUS	3	4266	4268	Reviewers Status	A=AD, G=Guard, R=Reservist, AGR=AGR, ART=ART, CIV=Civ, CTR=Ctr, OTH=Other
337	RRI5	RR_STATUS_TEXT	25	4269	4293	Reviewers Status Text	Text Field
338	RRI6	RR_TITLE	5	4294	4298	Reviewers Title	PHY=MD/DO, PA=PA, NP=NP, APN=APN, RN=RN, LN=LVN/LPN, IDMT=IDMT, IDC=IDC, IDHST=IDHST, SFMS=SFMS, MED=Medic, PHT=PHT, HST=HST, CL=Med Clerk, OTH=Other
339	RRI6	RR_TITLE_TEXT	50	4299	4348	Reviewers Title Text	Text Field
340	RRI7	RR_EMAIL	75	4349	4423	Reviewers Email	Text Field
341	RRI8	RR_FACILITY	50	4424	4473	Facility Name	Text Field
342	RRI9	RR_UNIT	50	4474	4523	Unit Name	Text Field
343	RRI10	RR_ADDR	60	4524	4583	Reviewers Address	Text Field
344	RRI11	RR_STATE	2	4584	4585	Reviewers STATE	Text Field
345	RRI12	RR_ZIP	10	4586	4595	Reviewers ZIP Code	Text Field
346	RRI13	RR_PHONE	20	4596	4615	Reviewers Phone number	Text Field
347	RRI14	RR_DATE	8	4616	4623	Date Record Review initiated	YYYYMMDD Format
348	RRII1	RR_PREV_PHA_DATE	8	4624	4631	Date of last documented PHA	YYYYMMDD Format
349	RRII1	RR_PREV_PHA_NONE	1	4632	4632	No documented PHA	1=Checked, 0=Not Checked
350	RRII2	RR_HEIGHT	2	4633	4634	Height in inches (convert from feet and inches)	99
351	RRII2	RR_HEIGHT_DATE	8	4635	4642	Date of Height record	YYYYMMDD Format
352	RRII2	RR_HEIGHT_NONE	1	4643	4643	No documented Height	1=Checked, 0=Not Checked
353	RRII3	RR_WEIGHT	3	4644	4646	Weight in pounds	999
354	RRII3	RR_WEIGHT_DATE	8	4647	4654	Date of weight record	YYYYMMDD Format
355	RRII3	RR_WEIGHT_NONE	1	4655	4655	No documented weight	1=Checked, 0=Not Checked
356	RRII4	RR_BP_DATE	8	4656	4663	Date of screen for Blood Pressure	YYYYMMDD Format
357	RRII4	RR_BP_SYSTOLIC	3	4664	4666	Systolic Blood Pressure	999
358	RRII4	RR_BP_DIASTOLIC	3	4667	4669	Diastolic Blood Pressure	999
359	RRII4	RR_BP_NONE	1	4670	4670	No Blood Pressure listed	1=Checked, 0=Not Checked
360	RRII5	RR_BP_ABN	1	4671	4671	history of abnormal blood pressure	Y=Yes, N=No
361	RRII6	RR_CHOL_DATE	8	4672	4679	Date of screen for Cholesterol	YYYYMMDD Format
362	RRII6	RR_CHOL_NONE	1	4680	4680	No documented cholesterol test	1=Checked, 0=Not Checked
363	RRII7	RR_COLON_DATE	8	4681	4688	Date of screen for colon cancer	YYYYMMDD Format
364	RRII7	RR_COLON_NONE	1	4689	4689	No colon cancer screening documented	1=Checked, 0=Not Checked
365	RRII8	RR_MEDS	200	4690	4889	List of medications	Text Field
366	RRII8	RR_MEDS_NONE	1	4890	4890	No active medications listed	1=Checked, 0=Not Checked
367	RRII9	RR_MEDS_DIFF	1	4891	4891	discrepancy between medications	Y=Yes, N=No
368	RRII9	RR_MEDS_DIFF_TEXT	200	4892	5091	List of medication discrepancies	Text Field
369	RRII10	RR_OUTSIDE_TEXT	200	5092	5291	List of documented care outside MHS	Text Field
370	RRII10	RR_OUTSIDE_NONE	1	5292	5292	No Outside care documented	1=Checked, 0=Not Checked
371	RRII11	RR_OUTSIDE_DIFF	1	5293	5293	Discrepancy between outside care listed and record	Y=Yes, N=No
372	RRII11	RR_OUTSIDE_DIFF_TEXT	200	5294	5493	List discrepancy between outside care listed and record	Text Field
373	RRII12	RR_INSIDE_TEXT	200	5494	5693	List of documented treatment or hospitalization	Text Field
374	RRII12	RR_INSIDE_NONE	1	5694	5694	No documented treatment or hospitalization	1=Checked, 0=Not Checked
375	RRII13	RR_SURG_COND1	100	5695	5794	Condition for which you had surgery	Text Field
376	RRII13	RR_SURG_COND2	100	5795	5894	Condition for which you had surgery	Text Field
377	RRII13	RR_SURG_COND3	100	5895	5994	Condition for which you had surgery	Text Field
378	RRII13	RR_SURG_TYPE1	100	5995	6094	Type of surgery	Text Field
379	RRII13	RR_SURG_TYPE2	100	6095	6194	Type of surgery	Text Field
380	RRII13	RR_SURG_TYPE3	100	6195	6294	Type of surgery	Text Field
381	RRII13	RR_SURG1	1	6295	6295	Documentation for surgery from DLC5: Cond1	Y=Yes, N=No, U=Record Unavailable
382	RRII13	RR_SURG2	1	6296	6296	Documentation for surgery from DLC5: Cond2	Y=Yes, N=No, U=Record Unavailable
383	RRII13	RR_SURG3	1	6297	6297	Documentation for surgery from DLC5: Cond3	Y=Yes, N=No, U=Record Unavailable
384	RRII14	RR_VAC_CONFIRM	1	6298	6298	Confirm that vaccine exemptions are listed	1=Confirmed, 2=Not confirmed
385	RRII14	RR_VAC_COMMENTS	100	6299	6398	Vaccine comments	Text Field
386	RRII15	RR_REC_REVIEW	1	6399	6399	Discrepancies in Documentation	1=Discrepancies, 2=No discrepancies
387	RRII15	RR_REC_REVIEW_TEXT	100	6400	6499	Comment on Document Discrepancies	Text Field
388	RRIII1	RR_DUTY_EXAM_DATE	8	6500	6507	Special operational duty physical exam date	YYYYMMDD Format
389	RRIII1	RR_DUTY_EXAM_REC	1	6508	6508	No documented exam	1=Checked, 0=Not Checked
390	RRIII1	RR_DUTY_EXAM_NONE	1	6509	6509	Record unavailable	1=Checked, 0=Not Checked
391	RRIII2	RR_MED_SURV_DATE	8	6510	6517	Medical surveillance / occ. health program exam date	YYYYMMDD Format
392	RRIII2	RR_MED_SURV_REC	1	6518	6518	No documented evaluation	1=Checked, 0=Not Checked
393	RRIII2	RR_MED_SURV_NONE	1	6519	6519	Record unavailable	1=Checked, 0=Not Checked
394	RRIV1	RR_FAM_HX	1	6520	6520	Does the 2766 reflect reported family history?	Y=Yes, N=No
395	RRIV1	RR_FAM_HX_TEXT	100	6521	6620	If No, then describe	Text Field
396	RRIV2	RR_STI_TEST_M	1	6621	6621	Record of receiving syphillis/chlamydia/gonorrhea test?	Y=Yes, N=No
397	RRV1	RR_PREG_WAIVER	1	6622	6622	profile and/or waiver in accordance with Service policy?	1=N/A, 2=No, 3=Yes
398	RRV2	RR_PREG_TEXT	100	6623	6722	Note if evaluated for any occupational health concerns associated with pregnancy	Text Field
399	RRV3	RR_PAP_DATE	8	6723	6730	Date of PAP	YYYYMMDD Format
400	RRV3	RR_PAP_RESULT	1	6731	6731	Results of PAP	1=Normal, 2=Abnormal, 3=No documented PAP
401	RRV4	RR_MAMMO_DATE	8	6732	6739	Date of weight Mammography	YYYYMMDD Format
402	RRV4	RR_MAMMO_NONE	1	6740	6740	No documented Mammography	1=Checked, 0=Not Checked
403	RRV5	RR_STI_TEST_F	1	6741	6741	Record of receiving syphillis/chlamydia/gonorrhea test?	Y=Yes, N=No
404	RRVI1	RR_2796_STATUS	1	6742	6742	Status of deployment assessment: 2796	1=Completed, 2=outside window, 3=Not completed (due), 4=Not completed (not due yet), 5=Not required
405	RRVI1	RR_2900_STATUS	1	6743	6743	Status of deployment assessment: 2900	1=Completed, 2=outside window, 3=Not completed (due), 4=Not completed (not due yet), 5=Not required
406	RRVI1	RR_DHA4_STATUS	1	6744	6744	Status of deployment assessment: DHA4	1=Completed, 2=outside window, 3=Not completed (due), 4=Not completed (not due yet), 5=Not required
407	RRVI1	RR_DHA5_STATUS	1	6745	6745	Status of deployment assessment: DHA5	1=Completed, 2=outside window, 3=Not completed (due), 4=Not completed (not due yet), 5=Not required
408	RRVI2	RR_2795_STATUS	1	6746	6746	Status of deployment assessment: 2795	Y=Yes, N=No
409	RRVII1	RR_PERM_PROFILE	1	6747	6747	Permanent Profile	Y=Yes, N=No
410	RRVII2	RR_TEMP_MOS	2	6748	6749	months in the past year has the Service member been in temporary duty	99
411	RRVII2	RR_TEMP_DATE	8	6750	6757	Date Temporary Situation Expires	YYYYMMDD Format
412	RRVII2	RR_TEMP_NONE	1	6758	6758	No Record of Temporary Situation	1=Checked, 0=Not Checked
413	RRVII3	RR_DENTAL_DATE	8	6759	6766	Date of Dental Exam	YYYYMMDD Format
414	RRVII3	RR_DENTAL_CLASS	1	6767	6767	recently documented dental exam	0=No Classification code, 1=1, 2=2, 3=3, 4=4
415	RRVII3	RR_DENTAL_NONE	1	6768	6768	No documented Dental Exam	1=Checked, 0=Not Checked
416	RRVII4	RR_IMM_CONF	1	6769	6769	current on all required immunizations	Y=Yes, N=No
417	RRVII4	RR_IMM_LIST	100	6770	6869	List Overdue Immunization(s):	Text Field
418	RRVII5	RR_GLASSES	1	6870	6870	current with Service-specific requirements for glasses	Y=Yes, N=No
419	RRVII5	RR_GLASSES_LIST	50	6871	6920	List	Text Field
420	RRVII6	RR_HIV_NONE	1	6921	6921	Documentation for HIV Test	Y=Yes, N=No
421	RRVII6	RR_G6PD	1	6922	6922	Documentation for G6PD result	Y=Yes, N=No
422	RRVII6	RR_BLOOD_TYPE	1	6923	6923	Documentation for Blood Type	Y=Yes, N=No
423	RRVII6	RR_DNA	1	6924	6924	Documentation for DNA test	Y=Yes, N=No
424	RRVIII1	RR_VA_RATING	3	6925	6927	Enter total disability rating (%)	999 (1-100 only)
425	RRVIII1	RR_VA_NONE	1	6928	6928	No documented VA disability rating	1=Checked, 0=Not Checked
426	RRIX1	RR_PROV_NOTIFIED	1	6929	6929	Provider notified	1=Checked, 0=Not Checked
427	RRIX1	RR_COM_NOTIFIED	1	6930	6930	Command notified	1=Checked, 0=Not Checked
428	RRIX1	RR_NO_NOTIFICATION	1	6931	6931	Notification is NOT required	1=Checked, 0=Not Checked
429	RRIX2	RR_COMMENTS	500	6932	7431	Reviewer Comments	Text Field
430	RRX1	RR_DIG_SIG	1	7432	7432	Reviewer Digital Signature	1=signed, 0=not signed
431	RRX2	RR_COMPLETE_DATE	8	7433	7440	Date record review completed	YYYYMMDD Format
432	HCP1	HCP_ASSESS	1	7441	7441	Indicate which assessment(s) you are completing:	1=Both, 2=PHA only, 3=MHA only
433	MHI1	MHP_LNAME	25	7442	7466	MHP provider's Last Name	Text Field

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it. Updated Dec 30, 2023.