Occupation Agency Code Work Location Work Supervisor Duty tel. #

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Transcription:

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 93-579 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: PERIODIC WHOLE BODY VIBRATION 511 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. Peripheral vascular disease, or do your fingers or toes turn color or become painful in cold weather 16. Headache, dizziness, light headedness, weakness 17. Nausea or vomiting 18. Change or loss of vision in either eye 19. Chest pain, angina, heart attack, irregular heart beat (arrhythmia), palpitation, or other heart problem 20. Repeated episodes of loss of or near loss of consciousness 21. Chronic abdominal pain, vomiting, other GI symptoms 22. Kidney disease 23. Problems with urination or blood in urine 24. Current pregnancy (females only) 25. Infertility or miscarriage (self or spouse) 26. Vibration white finger 27. Exposure to vibration (segmental or whole body) Page 1 of 5 Do not re-use this form after 5/20/2019

Medical History (continued) Comments on Medical History: Page 2 of 5 Do not re-use this form after 5/20/2019

Studies and Immunizations 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: Comments on Studies, Immunizations, and Vision: Page 3 of 5 Do not re-use this form after 5/20/2019

Vital Signs Blood pressure: Pulse: Respiratory rate: Temperature: Height: Weight: Physical Examination Eyes Cardiovascular system Abdomen Hemorrhoids Back & musculoskeletal system Peripheral vascular system, including acral (distal) micro-circulation and evidence of Reynaud s Varicose veins of lower extremities 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

Assessment Surveillance Examinations No abnormalities from occupational exposure Abnormalities from occupational exposure, limitations as noted below Pending WHOLE BODY VIBRATION (511) Disposition and Follow-up Released from Occupational Health Clinic Follow-up with PCM for Return for follow-up exams: WHOLE BODY VIBRATION. 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

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