B.06.05 Attachment 2 - Health History and Physical Examination Form.pdf

MEDICAL SURVEILLANCE PROGRAM

HEALTH HISTORY AND PHYSICAL EXAMINATION FORM

Employee/Applicant: A comprehensive history is an important part of your medical record.

Please complete 1-6 below:

1. Read the Privacy Act Notice, and the GINA statement below.

2. Print your name and the current date, where indicated, on each page of this form.

3. Answer all questions in Part 1 of this questionnaire (pages 2-5) by placing a check mark () or an X in the appropriate spaces, or printing other information where requested (use black or blue ink).

4. On page 5 in the Employee’s Comments space, Explain or discuss all of your Medical History or Review of Systems responses where you have indicated that you have had any of the listed conditions or symptoms.

5. Sign and date the form where requested on page 5.

6. Return the form to the clinic where your exam will be performed.

Privacy Act Statement The collection and use of this information is authorized by 5 U.S.C. 7901 (Health Service Programs) and 29 U.S.C. 657 (Occupational Health and Safety; Record Keeping). The information will become part of your official Employee Medical File, and will be used to assist the U.S. Army Corps of Engineers in carrying out its medical surveillance services responsibilities, and for other official purposes and routine uses as described in Privacy Act systems notice OPM/GOVT-10 (Employee Medical file System Records). Providing the requested information is voluntary. Not providing the information may affect the availability and quality of health services rendered to you, and may also affect the completeness of information used by your agency in making determinations of medically-related employment decisions.

GINA Statement

Title II of the Genetic Information Non-Discrimination Act (GINA) prohibits employers from requesting or requiring genetic information of an individual or using genetic information in making employment decisions. An exception is genetic information that is voluntarily provided by an employee as part of a voluntary wellness or physical fitness program. To comply with this law, we ask that you not provide any genetic information during the course of your medical examination. We also ask that clinical staff not ask, collect, or record genetic information.

Genetic information as defined by GINA includes an individual’s family medical history (knowledge about disease or medical disorders in family members), the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

Employee Name:____________________________________ 2

I. IDENTIFICATION

IDENTIFI

CATION

TODAY’S DATE: SEX: CHECK ONE:

MALE American Indian/ AK Native Hispanic

FEMALE Asian Pacific Islander

LAST NAME FIRST NAME (NO NICKNAMES) MIDDLE NAME White (non-Hispanic) Black

SOCIAL SECURITY NUMBER DATE OF BIRTH COUNTRY OF BIRTH STATE OF BIRTH CITY OF BIRTH

YOUR EMPLOYER: AGENCY DIVISION/ORGANIZATIONAL UNIT SUPERVISOR’S NAME SUPERVISOR’S PHONE NUMBER

YOUR OFFICIAL OPM JOB TITLE AND JOB SERIES

NUMBER

YOUR WORK BUILDING/FACILITY OR BUSINESS MAILING ADDRESS YOUR WORK PHONE NUMBER

YOUR HOME MAILING ADDRESSS CITY STATE ZIP YOUR HOME PHONE NUMBER

YOUR WORK E-MAIL ADDRESS YOUR HOME E-MAIL ADDRESS

II. MEDICATIONS None V. MEDICAL HISTORY None

List ALL medications (including prescription, non-prescription, vitamins, and herbal preparations) you currently take:

Which of the following conditions have YOU ever had?

(In brackets enter year of diagnosis. If unknown, place a in brackets).

[ ] Allergies Specify:

[ ] Anemia [ ] Herniated Disc

[ ] Asbestosis [ ] High Blood Pressure

[ ] Asthma [ ] Kidney Disease

[ ] Broken Bones [ ] Loss of Consciousness

III. SOCIAL HISTORY [ ] Cancer Specify Type:

Have you ever used tobacco? Yes No [ ] Chest Surgery [ ] Mental Health Disorders

If “yes,” when? Current Past – years since quitting? [ ] Chronic Bronchitis [ ] Migraines

Type: Cigarettes Pipe/Cigar Snuff/Chewing [ ] Claustrophobia [ ] Pneumonia

Amount per day? For how many years? [ ] Collapsed Lung [ ] Positive TB Skin Test

[ ] Denture Use [ ] Prostate Problems

What is your average alcohol consumption in a week? drinks [ ] Diabetes [ ] Ruptured Ear Drum

(1 drink = 12 oz. beer, 5 oz. wine or 1.5 oz. liquor) [ ] Emphysema [ ] Seizures

[ ] Head Injury [ ] Silicosis

If you drink alcohol, what is your usual pattern? [ ] Heart Attack [ ] Sleep Apnea

Weekdays Weekends Both [ ] Heart Murmur [ ] Trouble Smelling Odors

[ ] Hepatitis [ ] Thyroid Condition

IV. HOSPITALIZATIONS AND SURGERIES None Other:

YEAR Reason (continue on back, if more space is needed)

(if during the last 12 months, provide month, year and description)

My dominant hand is (check one): right handed left handed

VI. LEISURE ACTIVITIES

In which of the following hobbies / activities do you participate?

Painting Ceramics/Pottery Guns/Hunting

Gardening Refinishing Stained Glass

Auto/Boat Repair Power tool usage

Other (specify below):

Do you use safety equipment when you engage in these activities? Yes No

Part 1. Personal Information and Medical History (to be completed by the employee/applicant before the examination)

DO NOT LEAVE ANY SECTION BLANK; SPECIFY “N/A” (NOT APPLICABLE) IF APPROPRIATE.

Employee Name:____________________________________ 3

VII. PHYSICAL ACTIVITIES OR EXERCISE PROGRAM

Aerobic/Cardio Exercise: Light* Moderate* Vigorous* None * Levels of Exercise defined as:

Activities: (type of exercise) Light/Mild exertion (<3 METS) = walking 2.5 mph.

Frequency: (days per week) Moderate exertion (3-6 METS) = walking 3-4 mph, gardening, mowing lawn (power mower), leisure bicycling, golf, low impact aerobics, chopping wood.

Duration: (minutes/session)

Weight/Strength Exercise: Light* Moderate* Vigorous* None

Activities: (type of exercise) Vigorous exertion (>6 METS) = high impact aerobics, swimming laps, soccer, hiking, walking 4.5 mph, Frequency: (days per week)

Duration: (minutes/session) running 5 mph, basketball.

VIII. RESPIRATORY QUESTIONNAIRE (Complete this section even if no current or previous respirator use) Current Respirator Use: (check all that apply) No respirator used (continue with questions below)

Indicate the type of respirator you will use: Cartridge Air Supply SCBA Dust Mask/Disposable/N-95

How often will you use a respirator? daily 1-4 x/week 1-4 x/month 1-4 x/year

Hours of use in a typical day: <2 2—4 4—6 >6

Usual effort while wearing respirator: light moderate heavy

Environmental conditions present during respirator use (check all that apply):

high altitude temperature extremes confined spaces post-fire/blast scenes

Do you wear contact lenses? Yes No

Do you wear glasses? Yes No

Past Respirator Use:

Have you had previous respirator use? Yes No

Any difficulties with past respirator use? Yes No

If Yes, what kind of difficulties: Eye irritation Skin allergies/rashes Anxiety General weakness or fatigue

Any other problem that interferes with your use of a respirator: Yes No If yes, what:

Do you currently have any of the following symptoms of lung illness?

Shortness of breath Yes No

Shortness of breath when walking fast on level ground or walking up a slight hill or incline Yes No

Shortness of breath when walking with other people at an ordinary pace on level ground Yes No

Have to stop for breath when walking at your own pace on level ground Yes No

Shortness of breath when washing or dressing yourself Yes No

Shortness of breath that interferes with your job Yes No

Coughing that produces phlegm (thick sputum) Yes No

Coughing that wakes you early in the morning Yes No

Coughing that occurs mostly when you are lying down Yes No

Coughing up blood in the last month Yes No

Wheezing Yes No

Wheezing that interferes with your job Yes No

Chest pain when you breathe deeply Yes No

Any other symptoms that you think may be related to lung Yes No

Have you ever had any of the following cardiovascular or heart symptoms?

Frequent pain or tightness in your chest Yes No

Pain or tightness in your chest during physical activity Yes No

Pain or tightness in your chest that interferes with your job Yes No

In the past two years, have you noticed your heart skipping or missing a beat Yes No

Heartburn or symptoms that are not related to eating Yes No

Any other symptoms that you think may be related to heart or circulation problems Yes No

DO NOT LEAVE ANY SECTION BLANK; SPECIFY “N/A” (NOT APPLICABLE) IF APPROPRIATE

Employee Name:____________________________________ 4

VIII. RESPIRATORY QUESTIONNAIRE (continued) Do you currently have any of the following musculoskeletal problems?

Weakness in any of your arms, hands, legs, or feet Yes No

Back pain Yes No

Difficulty fully moving your arms or legs Yes No

Pain or stiffness when you lean forward or backward at the waist Yes No

Difficulty fully moving your head up or down Yes No

Difficulty fully moving your head side to side Yes No

Difficulty bending at your knees Yes No

Difficulty squatting to the ground Yes No

Difficulty climbing a flight of stairs or a ladder while carrying more than 25 lbs. Yes No

Any other muscle or skeletal problem that interferes with using a respirator Yes No

IX. OCCUPATIONAL HISTORY

Briefly describe the physical activities of your current job: (such as climb ladders, fieldwork, drive vehicles, operate forklift, heavy lifting, etc.):

How long have you been doing this type of work? years

Have you ever been off work more than a day because of work-related illness or injury? Yes No

If yes, provide medical condition and year:

Have you ever changed jobs or duties due to health problems? Yes No

If yes, provide medical condition and year:

Have you ever been placed on temporary restricted/limited duty with your CURRENT employer due to an illness/injury? Yes No

If yes, specify condition and year: Was it work related? Yes No

What were the restrictions?

How long were/are they in effect?

If this is your FIRST medical surveillance exam, list all outside or previous jobs, starting with the one before your current position:

Agency/Company Dates of Employment

(from – to) Job Duties Specific Hazards*

* Hazards may include asbestos, chemicals, dusts, silica, beryllium, tungsten, cobalt, chromium, aluminum dust, coal, iron, tin, fumes, gases, radiation, vibration, repetitive motion, intense light and loud noise, or any other recognized hazards.

* For any asbestos exposure, please indicate the year and place of first exposure, regardless of use of protective equipment.

Employee Name:____________________________________ 5

X. REVIEW OF SYSTEMS – Which of the following have been a problem for you in the last year? NONE

General/Constitutional Heart/Lungs Skin/Musculoskeletal

Fever > 100° Chest pain or pressure Rashes

Shivering/Chills Irregular heart beat Moles that changed in size or color

Generalized weakness Palpitations/skipped beats Muscle pain

Unexplained weight loss/gain New or changed cough Back pain

Excessive fatigue Coughing up blood Neck pain

Swollen glands Wheezing Weakness in arms/legs

Loss of appetite Shortness of breath Joint pain (which joints?): ____________

Eyes Digestive System Genitourinary/Reproductive Change in vision Nausea/vomiting Difficult or painful urination

Itching Diarrhea/Constipation (circle one or both) Blood in urine

Tearing Yellow jaundice Difficulty having children N/A

Rectal bleeding or black tarry stools

Men Only N/A

Ears, Nose, Throat Neurologic/Psychiatric Lump in testicle Difficulty hearing Headaches

Ringing/buzzing Dizziness/passing out (circle one or both) Women Only N/A

Sinus trouble Depression Irregular periods/spotting

Congestion Numbness or tingling Miscarriage or stillborn pregnancy

Sneezing/runny nose Excessive anxiety Breast lump/discharge

Nosebleeds Insomnia/difficulty sleeping Currently or possibly pregnant

Difficulty swallowing Loss of memory Last menstrual period?

Employee’s Comments: All responses above should be explained by indicating if they are mild, moderate, or severe, years present, if they interfere with work activities and results of medical evaluation, if known. (For example: mild back pain for 10 years, only when doing heavy work-out in the gym, does not interfere with work activities, no medical evaluation.)

I certify that all of the information I have provided on this form is complete and accurate to the best of my knowledge, and that submitting information that is incomplete, misleading, or untruthful may result in termination, criminal sanctions, or delays in processing this form for employment. Furthermore, consistent with the Privacy Act Statement (on page 1), I authorize the release to my employing agency of all information contained on this examination form and all other forms generated as a direct result of my occupational health examination. The information will be used strictly for official purposes, as outlined on page 1.

Signature of Applicant/Employee Date:

Examiner’s Comments: Explain all positive responses in Review of Systems here to include location, severity, how long present, exacerbating activities, treatment, whether you believe they impact work duties and results of medical evaluations (continue on page 7). ALSO:

1. Next to MEDICATIONS (page 2) comment on: (a) reason used if not obvious (e.g. antiepileptic medication for treatment of restless leg syndrome);

(b) location of pain treated with narcotic medication; and (c) frequency of use and time of day of use of sedating medications.

2. Next to HOSPITALIZATIONS/SURGERIES (page 2) clarify dates and nature of hospitalizations/surgeries.

3. Next to RESPIRATORY QUESTIONNAIRE (pages 3 and 4) explain positive responses: (a) when symptoms occur; (b) medical cause; (c) results of medical evaluations; and (d) if shortness of breath, explain exercise tolerance or # of flights of stairs employee can climb continuously.

Employee Name:____________________________________ 6

Part II. Physical Examination (to be completed by the examiner at the time of the examination)

DO NOT LEAVE ANY SECTION BLANK; SPECIFY “N/A” (NOT APPLICABLE) IF APPROPRIATE

Vital Signs: ________(in.) ________(lb.) / (mm/Hg) / (mm/Hg) _________ ________ __________ _______________ ______________

Height Weight Blood Pressure #1 Blood Pressure #2 Pulse Resp. Temp. BMI Abdominal Girth (Required if BP#1 > 140/90)

Has employee received Hepatitis B Vaccine? Yes No If “Yes”, # of shots: 1 2 3 Year completed: __________

Year of last Tetanus Booster: _________ Year of last chest x-ray: __________

Tonometry: O.D: mm/Hg Mantoux mm induration Stool for neg. x _____

Dr./Nurse Comments:

O.S: mm/Hg (PPD) not done Occult positive not done Blood not done

Vision: Testing Method: screening machine wall/hand held chart

If best far vision worse than 20/40 in both or either eye retest with Snellen Wall Chart.

If best near vision worse than 20/40 in both or either eye retest with Jaegar or Rosenbaum Card.

Uncorrected: With Correction: Contacts Glasses Surgery

Far: OU (both) 20/__________ Far: OU (both) 20/__________

OD (right) 20/__________ OD (right) 20/__________

OS (left) 20/__________ OS (left) 20/__________

Near: OU (both) 20/__________ Near: OU (both) 20/__________

OD (right) 20/__________ OD (right) 20/__________

OS (left) 20/__________ OS (left) 20/__________

Depth Perception:

Test Type: (e.g.: Titmus)

Number Correct:________ of _______ tested

Seconds of arc: _________

Peripheral Vision (degrees) Color Vision (test used): _____________________

Right Temporal ° ______ Left Temporal ° ________ Number Correct: _________ of _________ tested

Nasal ° ________ Nasal ° ________ Can see red/green/yellow? Yes No

Total ° ________ Total ° ________ Client has monocular vision? Yes No

Physical Examination: (MUST PROVIDE FINDINGS THAT EVALUATE REPORTED MEDICAL CONDITIONS (For example, for lower back pain provide findings of ROM, results of SLR test, sensation/motor strength, reflexes and ability to squat, etc.) If an examination element is not done, indicate if “not age-appropriate” or “patient refused.”

Normal Abnormal Not Done

General

Skin

Head

Eyes

Ears

Nose

Mouth

Throat

Neck

Thyroid

Lymph Nodes

Lungs

Breasts

Heart

Abdomen

Genitalia

Rectal

Extremities

Arterial Pulses

Musculoskeletal

Neurological

Mental Status

Health Center Stamp

Employee Name:____________________________________ 7

Part III. Examiner’s Summary MEDICAL CONDITIONS AND FINDINGS BASED ON MEDICAL HISTORY AND PHYSICAL EXAMINATION

(to be completed by the examiner at the time of the examination)

DO NOT LEAVE ANY SECTION BLANK

Abnormal Abnormal

Normal Clinically Insignificant Clinically Significant Not Done

Laboratory Results Were:

Electrocardiogram Was:

Physical Examination Was:

Medical Conditions:

(if none, indicate “healthy”)

Comments: (include documentation of control, h/o evaluation, outside test results, and severity, etc.)

--R e f e r r e d-- Routine Urgent

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EDUCATION SUMMARY:

Protective Equipment, including: Preventive Health Measures, including:

Hearing Protection Smoking cessation Self-Examination (breast, testicular)

Safety Glasses Dangers of smoking and asbestos exposure Universal Precautions for BBP

Respirator use Reduce or stop alcohol consumption Avoid sun exposure / Use sun block

Gloves/Skin protection Participate in regular cancer screening Other:

Seat Belts

Other:

The examiner’s signature indicates that: (a) the examination is complete; and (b) all medical tests and lab results were reviewed and discussed with the employee where applicable and (c) pertinent positive and negative results were used to complete the medical conditions/findings section above.

Name of Examiner (print) Examiner’s Signature Date

Examiner, please have the client sign below to document counseling was received and understood:

I have received a copy of the summary of my examination and understand the findings:

Employee Signature Date