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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: BASELINE CRESOL 135 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. Allergies (asthma, hay fever, eczema) 16. Skin disease, rash, erosion, ulcer, eczema, pigmentation abnormality or other skin abnormality 17. Hepatitis or jaundice 18. Lung or respiratory disease (ex: COPD, bronchitis, pneumonia, asbestosis, silicosis, pneumothorax / collapsed lung) 19. Shortness of breath 20. Headache, dizziness, light headedness, weakness 21. Nausea or vomiting 22. Chest pain, angina, heart attack, irregular heart beat (arrhythmia), palpitation, or other heart problem 23. Coughing up blood (hemoptysis) 24. Cough, other than with colds, flu or allergies 25. Liver disease 26. Kidney disease 27. Numbness, tingling, or weakness in hands or feet 28. Exposure to skin irritants 29. Exposure to respiratory irritants OF BIRTH (DD-MMM-YYYY) Page 1 of 5 Do not re-use this form after 11/14/2017

Medical History (continued) Comments on Medical History: OF BIRTH (DD-MMM-YYYY) Page 2 of 5 Do not re-use this form after 11/14/2017

Studies and Immunizations Chemistry: BUN Creatinine AST 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: Chest X-ray (PA) Comments on Studies, Immunizations, and Vision: OF BIRTH (DD-MMM-YYYY) Page 3 of 5 Do not re-use this form after 11/14/2017

Vital Signs Blood pressure: Pulse: Respiratory rate: Temperature: Height: Weight: Physical Examination Respiratory system Liver Skin (rash, erosion, ulcer, pigment, eczema, etc.) Central nervous system Peripheral nervous system (strength, sensation, DTRs) WNL Other (describe) Comments on Physical Exam findings: OF BIRTH (DD-MMM-YYYY) Page 4 of 5 Do not re-use this form after 11/14/2017

Assessment Surveillance Examinations No abnormalities from occupational exposure Abnormalities from occupational exposure, limitations as noted below Pending CRESOL (135) Disposition and Follow-up Released from Occupational Health Clinic Follow-up with PCM on or in Return for follow-up exams: CRESOL in 1 year. Other disposition: Discussed results of exam with employee Limitations and comments: Provider Signature & Stamp: Date: OF BIRTH (DD-MMM-YYYY) Page 5 of 5 Do not re-use this form after 11/14/2017

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