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: TERMINATION FIREFIGHTER (COMPREHENSIVE) 707 CERTIFICATION 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. 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. Use of seat belts (circle: always, mostly, some, none) 15. Any reproductive health concerns 16. Blood diseases (anemia, abnormal bleeding or clotting, etc) 17. Allergies (asthma, hay fever, eczema) 18. Have you ever been evaluated for latex allergy 19. Skin disease, rash, erosion, ulcer, eczema, pigmentation abnormality or other skin abnormality 20. Heat injury (heat cramps, exhaustion, stroke) 21. Difficulty acclimating to heat 22. Peripheral vascular disease, or do your fingers or toes turn color or become painful in cold weather 23. Hepatitis or jaundice 24. Lung or respiratory disease (ex: COPD, bronchitis, pneumonia, asbestosis, silicosis, pneumothorax / collapsed lung) 25. Wheezing 26. Tuberculosis or PPD Converter 27. Chest surgery or injury (including broken ribs) 28. Shortness of breath 29. Headache, dizziness, light headedness, weakness 30. Exposure (acclimatization) to heat 31. Cold injury (frostbite, chill, trench foot, hypothermia) 32. Head injury 33. Use of eye glasses 34. Change or loss of vision in either eye Page 1 of 6 Do not re-use this form after 5/20/2019
2 Medical History (continued) 35. Contact lens use 36. Color blindness 37. Eye irritation or blurred vision 38. Any other eye or vision problem 39. Inability or reduced ability to smell 40. Ringing in the ear (tinnitus) 41. Any injury to your ears (including ruptured ear drum) 42. Change or loss in hearing 43. A need to wear a hearing aid 44. Any other hearing or ear problem 45. Difficulty hearing conversations, people 46. Recreational or non-occupational exposure to loud noise 47. Chest pain, angina, heart attack, irregular heart beat (arrhythmia), palpitation, or other heart problem 48. Repeated episodes of loss of or near loss of consciousness 49. Frequent pain or tightness in your chest 50. Swelling in legs or feet (not caused by walking) 51. Cough, other than with colds, flu or allergies 52. Chronic abdominal pain, vomiting, other GI symptoms 53. Kidney disease 54. Current pregnancy (females only) 55. Infertility or miscarriage (self or spouse) 56. Epilepsy or seizures 57. Problems with balance or coordination 58. Numbness, tingling, or weakness in hands or feet 59. Thyroid disease (including heat or cold intolerance) 60. Diabetes (sugar disease) or other endocrine disorder (thyroid, parathyroid, pituitary, adrenal gland) 61. Mental or emotional illness 62. Sleep disorder, breathing pauses while sleeping, sleep apnea, loud snoring, insomnia, daytime sleepiness 63. Depression, difficulty concentrating, excessive anxiety 64. Personality or behavior change 65. Claustrophobia 66. Muscle or joint problems, rheumatism, or arthritis 67. Any other muscle or skeletal problem that may interfere with using a respirator 68. Latex allergy or sensitivity 69. Do you have any symptoms which you think may be related to hazards you are exposed to at work 70. Prior respirator use 71. Any problems with prior respirator use 72. Exposure to excessive noise 73. Exposure to skin irritants 74. Exposure to respiratory irritants 75. Exposure to carcinogens 76. Exposure to potentially infectious body fluids Page 2 of 6 Do not re-use this form after 5/20/2019
3 Medical History (continued) Comments on Medical History: Page 3 of 6 Do not re-use this form after 5/20/2019
4 Studies and Immunizations Chemistry: Fasting blood glucose BUN Creatinine AST ALT Bilirubin, Total Alkaline phosphatase Total protein GGT Albumin Other studies or comments: Urine: Urine Ph Urine specific gravity Urine urobilinogen Urine protein Urine glucose Urine ketones Urine blood Urine nitrite Urine RBCs Urine WBCs Other studies or comments: Blood counts: RBC WBC HGB MCV MCH MCHC HCT Neutrophils Lymphocytes Monocytes Eosinophils Basophils Platelets Other studies or comments: Audiogram (DD 2215/2216) Spirometry FVC FEV1 FEV1/FVC Rate of FEV1 Decline (% or ml/yr Comments Color vision Pass Fail Ishihara - # of plates HRR (Hardy Rand Ritter) City University Farnsworth D15 Other Comments on Studies, Immunizations, and Vision: Page 4 of 6 Do not re-use this form after 5/20/2019
5 Vital Signs Blood pressure: Pulse: Respiratory rate: Temperature: Height: Weight: Physical Examination Overall physical fitness Metabolic disturbance (fever, tachycardia) Eyes Ears (tympanic membranes) Thyroid Cardiovascular system Respiratory system Liver Check for inguinal or femoral hernia Back & musculoskeletal system Skin (rash, erosion, ulcer, pigment, eczema, etc.) Central nervous system Peripheral nervous system (strength, sensation, DTRs) Psychiatric (especially emotional stability) Evidence of recent or current substance abuse Other appropriate examination (specify) WNL Other (describe) Comments on Physical Exam findings: Page 5 of 6 Do not re-use this form after 5/20/2019
6 Assessment Blood & body fluid precautions knowledge adequate Certification Examinations Qualified Not Qualified Pending FIREFIGHTER (COMPREHENSIVE) (707) 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 Surveillance/PPE consistent with exposures Abnormalities possibly related to exposures/occupations Limitations and comments: Provider Signature & Stamp: Date: Page 6 of 6 Do not re-use this form after 5/20/2019
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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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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