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 EXPLOSIVES HANDLER AND EXPLOSIVES MATERIAL HANDLING EQUIPMENT OPERATOR 721 CERTIFICATION 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. Use of seat belts (always, mostly, some, none) 15. Any reproductive health concerns 16. Peripheral vascular disease, or do your fingers or toes turn color or become painful in cold weather 17. Lung or respiratory disease (ex: COPD, bronchitis, pneumonia, asbestosis, silicosis, pneumothorax / collapsed lung) 18. Headache, dizziness, light headedness, weakness 19. Nervous stomach or ulcer 20. Head injury 21. Change or loss of vision in either eye 22. Change or loss in hearing 23. Chest pain, angina, heart attack, irregular heart beat (arrhythmia), palpitation, or other heart problem 24. Repeated episodes of loss of or near loss of consciousness 25. Kidney disease 26. Epilepsy or seizures 27. Problems with balance or coordination 28. Numbness, tingling, or weakness in hands or feet 29. Migraine headache 30. Diabetes (sugar disease) or other endocrine disorder (thyroid, parathyroid, pituitary, adrenal gland) 31. Mental or emotional illness 32. Sleep disorder, breathing pauses while sleeping, sleep apnea, loud snoring, insomnia, daytime sleepiness 33. Depression, difficulty concentrating, excessive anxiety Page 1 of 5 Do not re-use this form after 11/14/2017
Medical History (continued) 34. Treatment for drug or alcohol use 35. Personality or behavior change 36. Muscle or joint problems, rheumatism, or arthritis 37. Permanent defect from illness, disease or injury 38. Do you take any prescribed or unprescribed stimulants besides caffeine 39. Do you take any prescribed or unprescribed habit-forming drug 40. Are you seeing or being treated by a psychiatrist, psychologist or counselor 41. Have you ever been diagnosed with alcoholism Comments on Medical History: Page 2 of 5 Do not re-use this form after 11/14/2017
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: Audiogram (non-hcp) Vision With Correction Without Correction DISTANCE NEAR Right Left Both Right Left 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / Visual fields Horizontal (lateral) field of vision, degrees Right Left Color vision Pass Fail Ishihara - # of plates HRR (Hardy Rand Ritter) City University Farnsworth D15 Other Comments on Studies, Immunizations, and Vision: 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 Eyes Ears (tympanic membranes) Throat Cardiovascular system Respiratory system Abdomen Check for inguinal or femoral hernia Back & musculoskeletal system Extremities Peripheral vascular system, including acral (distal) micro-circulation and evidence of Reynaud s 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 11/14/2017
Assessment Certification Examinations Qualified Not Qualified Pending EXPLOSIVES HANDLER and EXPLOSIVES MATERIAL HANDLING EQUIPMENT OPERATOR (721) Disposition and Follow-up Released from Occupational Health Clinic Follow-up with PCM on or in Return for follow-up exams: EXPLOSIVES HANDLER and EXPLOSIVES MATERIAL HANDLING EQUIPMENT OPERATOR in 5 years. 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 11/14/2017