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 OCONUS DEPLOYMENT GREATER THAN 30 DAYS 798 CERTIFICATION EXAMINATION Medical History 1. Is your work exposure history current (OPNAV 5100/15), and is surveillance/ppe consistent with exposures/occupations 2. Is your Periodic Health Assessment (PHA) current 3. Is your Pre-Deployment Health Assessment current (DD 2795) 4. Has anything about your health status changed since your last examination 5. Have any medications changed since your last exam 6. Major illness or injury 7. Hospitalization or surgery 8. Cancer 9. Back injury 10. Do you drink 6 or more drinks per week (beer, wine, liquor) 11. Have you ever smoked 12. Do you currently smoke or use smokeless tobacco or electronic cigarettes ( packs/day) 13. Heart disease, high blood pressure, stroke or circulation problems 14. Current medication use (prescription or over the counter) 15. Medication allergies 16. Any reproductive health concerns 17. Allergies (asthma, hay fever, eczema) 18. Color blindness 19. Kidney disease 20. Current pregnancy (females only) 21. Problems with balance or coordination 22. Numbness, tingling, or weakness in hands or feet 23. Unexplained fatigue 24. Thyroid disease (including heat or cold intolerance) 25. Diabetes (sugar disease) or other endocrine disorder (thyroid, parathyroid, pituitary, adrenal gland) 26. Sleep disorder, breathing pauses while sleeping, sleep apnea, loud snoring, insomnia, daytime sleepiness 27. Permanent defect from illness, disease or injury 28. Psychological disorders, Depression 29. Do you currently have 2 pairs of glasses and/or contacts OF BIRTH (DD-MMM-YYYY) Page 1 of 6 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 6 Do not re-use this form after 11/14/2017
Studies and Immunizations Chemistry: HgbA1C (if Diabetic) Urine: Urine Ph Blood counts: RBC Immunizations: MMR #1 Blood type Urine specific gravity WBC MMR #2 Cholesterol, total Urine urobilinogen HGB Measles titer LDL Urine protein MCV Mumps titer HDL Urine glucose MCH Rubella titer Triglycerides Urine ketones MCHC Varicella vaccine #1 AST ALT Urine blood Urine nitrite Varicella vaccine #2 Varicella titer Bilirubin, Total Urine RBCs Hepatitis B vaccine #1 Alkaline phosphatase Urine WBCs Hepatitis B vaccine #2 HIV DNA Hepatitis B vaccine #3 Hepatitis B titer G6PD Hepatitis A vaccine #1 HCG Hepatitis A vaccine #2 Td (Tdap once) Meningococcal Polio Typhoid Yellow Fever Anthrax Smallpox Japanese Encephalitis Virus Tuberculosis screening questionnaire Audiogram (DD 2215/2216) Electrocardiogram Dental screen (Class I or II) Vision With Correction Without Correction DISTANCE NEAR Right Left Both Right Left 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / OF BIRTH (DD-MMM-YYYY) Page 3 of 6 Do not re-use this form after 11/14/2017
Color vision Pass Fail Ishihara - # of plates HRR (Hardy Rand Ritter) City University Farnsworth D15 Other Comments on Studies, Immunizations, and Vision: OF BIRTH (DD-MMM-YYYY) Page 4 of 6 Do not re-use this form after 11/14/2017
Vital Signs Blood pressure: Pulse: Respiratory rate: Temperature: Height: Weight: Physical Examination Eyes Ears (tympanic membranes) Cardiovascular system Respiratory system Abdomen Check for inguinal or femoral hernia Back & musculoskeletal system Extremities 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 5 of 6 Do not re-use this form after 11/14/2017
Assessment Certification Examinations Qualified Not Qualified Pending OCONUS DEPLOYMENT GREATER THAN 30 DAYS (798) Disposition and Follow-up Released from Occupational Health Clinic Follow-up with PCM on or in Return for follow-up exams: OCONUS DEPLOYMENT GREATER THAN 30 DAYS in. Other disposition: Discussed results of exam with employee Limitations and comments: Provider Signature & Stamp: Date: OF BIRTH (DD-MMM-YYYY) Page 6 of 6 Do not re-use this form after 11/14/2017