Occupation Agency Code Work Location Work Supervisor Duty tel. #
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1 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 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: BASELINE CADMIUM (PAST EXPOSURE) 206 SURVEILLANCE EXAMINATION Medical History 1. Is your work exposure history current (OPNAV 5100/15), 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. Major illness or injury 5. Hospitalization or surgery 6. Cancer 7. 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. Lung or respiratory disease (ex: COPD, bronchitis, pneumonia, asbestosis, silicosis, pneumothorax / collapsed lung) 18. Treatment with steroids, immunosupressive or cancer (cytotoxic) drugs 19. Shortness of breath 20. Chest pain, angina, heart attack, irregular heart beat (arrhythmia), palpitation, or other heart problem 21. Repeated episodes of loss of or near loss of consciousness 22. Coughing up blood (hemoptysis) 23. Cough, other than with colds, flu or allergies 24. Liver disease 25. Injury with heavy bleeding in last year 26. Blood in stool 27. Seizures or fits 28. Kidney disease 29. Kidney stones 30. Problems with urination or blood in urine 31. Prostate gland problems 32. Protein in urine 33. Current pregnancy (females only) 34. Impotence or sexual dysfunction Page 1 of 5 Do not re-use this form after 11/14/2017
2 Medical History (continued) 35. Thyroid disease (including heat or cold intolerance) 36. Diabetes (sugar disease) or other endocrine disorder (thyroid, parathyroid, pituitary, adrenal gland) 37. Bone problems (including broken bones) 38. Musculoskeletal problems 39. Exposure to cadmium Comments on Medical History: Page 2 of 5 Do not re-use this form after 11/14/2017
3 Studies and Immunizations Chemistry: Cadmium (CdB) BUN Creatinine AST ALT Bilirubin, Total Alkaline phosphatase Other studies or comments: Urine: Urine Ph Urine specific gravity Urine urobilinogen Urine protein Urine glucose Urine ketones Urine blood Urine nitrite Urine Cadmium (CdU) Urine Beta 2 microglobulin Other studies or comments: Chest X-ray (PA) Spirometry FVC FEV1 FEV1/FVC Comments Comments on Studies, Immunizations, and Vision: Page 3 of 5 Do not re-use this form after 11/14/2017
4 Vital Signs Blood pressure: Pulse: Respiratory rate: Temperature: Height: Weight: Physical Examination Respiratory system Prostate palpation or other at-least-as-effective diagnostic test(s) for males over 40 years old WNL Other (describe) Comments on Physical Exam findings: Page 4 of 5 Do not re-use this form after 11/14/2017
5 Assessment Surveillance Examinations No abnormalities from occupational exposure Abnormalities from occupational exposure, limitations as noted below Pending CADMIUM (PAST EXPOSURE) (206) Disposition and Follow-up Released from Occupational Health Clinic Follow-up with PCM on or in Return for follow-up exams: CADMIUM (PAST EXPOSURE) in. Other disposition: Discussed results of exam with employee Physician opinion letter provided Limitations and comments: Provider Signature & Stamp: Date: Page 5 of 5 Do not re-use this form after 11/14/2017
Occupation Agency Code Work Location Work Supervisor Duty tel. #
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
Occupation Agency Code Work Location Work Supervisor Duty tel. #
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
Occupation Agency Code Work Location Work Supervisor Duty tel. #
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
Occupation Agency Code Work Location Work Supervisor Duty tel. #
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
Occupation Agency Code Work Location Work Supervisor Duty tel. #
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
Occupation Agency Code Work Location Work Supervisor Duty tel. #
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
Occupation Agency Code Work Location Work Supervisor Duty tel. #
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
Occupation Agency Code Work Location Work Supervisor Duty tel. #
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
Occupation Agency Code Work Location Work Supervisor Duty tel. #
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
Occupation Agency Code Work Location Work Supervisor Duty tel. #
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
Occupation Agency Code Work Location Work Supervisor Duty tel. #
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
Occupation Agency Code Work Location Work Supervisor Duty tel. #
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
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