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 ORGANOTIN COMPOUNDS 180 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. 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. Skin disease, rash, erosion, ulcer, eczema, pigmentation abnormality or other skin abnormality 16. Lung or respiratory disease (ex: COPD, bronchitis, pneumonia, asbestosis, silicosis, pneumothorax / collapsed lung) 17. Headache, dizziness, light headedness, weakness 18. Nausea or vomiting 19. Diarrhea 20. Change or loss of vision in either eye 21. Eye irritation or blurred vision 22. Inability or reduced ability to smell 23. Liver disease 24. Incontinence 25. Numbness, tingling, or weakness in hands or feet 26. Personality or behavior change 27. Psychological disorders, Depression 28. Exposure to skin irritants 29. Exposure to respiratory irritants Page 1 of 5 Do not re-use this form after 5/20/2019
2 Medical History (continued) Comments on Medical History: Page 2 of 5 Do not re-use this form after 5/20/2019
3 Studies and Immunizations Chemistry: AST Bilirubin, Total Alkaline phosphatase Urine: Urine Ph Urine specific gravity Urine urobilinogen Urine protein Urine glucose Urine ketones Urine blood Urine nitrite Blood counts: RBC WBC HGB MCV MCH MCHC Neutrophils Lymphocytes Monocytes Eosinophils Basophils Spirometry FVC FEV1 FEV1/FVC Rate of FEV1 Decline (% or ml/yr Comments Vision With Correction Without Correction DISTANCE NEAR Right Left Both Right Left Both 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / Comments on Studies, Immunizations, and Vision: Page 3 of 5 Do not re-use this form after 5/20/2019
4 Vital Signs Blood pressure: Pulse: Respiratory rate: Temperature: Height: Weight: Physical Examination Eyes Respiratory system Liver Kidneys Skin (rash, erosion, ulcer, pigment, eczema, etc.) Central nervous system WNL Other (describe) Comments on Physical Exam findings: Page 4 of 5 Do not re-use this form after 5/20/2019
5 Assessment Surveillance Examinations No abnormalities from occupational exposure Abnormalities from occupational exposure, limitations as noted below Pending ORGANOTIN COMPOUNDS (180) Disposition and Follow-up Released from Occupational Health Clinic Follow-up with PCM for Return for follow-up exams: ORGANOTIN COMPOUNDS. Other disposition: Discussed results of exam with employee Limitations and comments: Provider Signature & Stamp: Date: Page 5 of 5 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
GoPrivateMD General Information & History
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
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