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 CARBON DISULFIDE 126 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. Use of nitrate medication (nitroglycerine) 16. Headache, dizziness, light headedness, weakness 17. Nausea or vomiting 18. Change or loss of vision in either eye 19. Eye irritation or blurred vision 20. Glaucoma 21. Chest pain, angina, heart attack, irregular heart beat (arrhythmia), palpitation, or other heart problem 22. Repeated episodes of loss of or near loss of consciousness 23. Infertility or miscarriage (self or spouse) 24. Epilepsy or seizures 25. Numbness, tingling, or weakness in hands or feet 26. Tremor (shakiness) or loss of sensation/feeling 27. Mental or emotional illness 28. Depression, difficulty concentrating, excessive anxiety 29. Personality or behavior change 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 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 RBCs Urine WBCs Other studies or comments: Electrocardiogram 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 / Visual fields Horizontal (lateral) field of vision, degrees Comments on Studies, Immunizations, and Vision: Right Left 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 Cardiovascular system Liver Kidneys Skin (rash, erosion, ulcer, pigment, eczema, etc.) Central nervous system Peripheral nervous system (strength, sensation, DTRs) 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 CARBON DISULFIDE (126) Disposition and Follow-up Released from Occupational Health Clinic Follow-up with PCM for Return for follow-up exams: CARBON DISULFIDE. 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
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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