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 HEALTH CARE WORKERS (HCWS) 719 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. Any reproductive health concerns 15. Allergies (asthma, hay fever, eczema) 16. Have you ever been evaluated for latex allergy 17. Skin disease, rash, erosion, ulcer, eczema, pigmentation abnormality or other skin abnormality 18. Hepatitis or jaundice 19. Tuberculosis or PPD Converter 20. History of chicken pox 21. Current pregnancy (females only) 22. Infertility or miscarriage (self or spouse) 23. Adverse reaction to eating any vegetable or fruit 24. Latex allergy or sensitivity 25. Multiple operations or chronic medical instrumentation 26. Unexplained hives or symptoms of shock 27. Itchy eyes, runny nose, respiratory symptoms when using latex gloves 28. Exposure to chemotherapeutic or antineoplastic agents 29. Exposure to aerosolized antibiotics or antivirals 30. Exposure to anesthetic gases 31. Exposure to ethylene oxide 32. Exposure to ionizing radiation 33. Exposure to non-ionizing radiation (laser, infra-red, microwave (except ovens), ultraviolet) 34. Exposure to potentially infectious body fluids Page 1 of 5 Do not re-use this form after 11/14/2017
Medical History (continued) 35. Exposure to formaldehyde 36. Regular contact with latex gloves or other rubber products Comments on Medical History: Page 2 of 5 Do not re-use this form after 11/14/2017
Studies and Immunizations Immunizations: MMR #1 MMR #2 Measles titer Mumps titer Rubella titer Varicella vaccine #1 Varicella vaccine #2 Varicella titer Hepatitis B vaccine #1 Hepatitis B vaccine #2 Hepatitis B vaccine #3 Hepatitis B titer Td (Tdap once) Seasonal Influenza Vaccination Tuberculosis screening questionnaire Tuberculosis skin/blood test Other studies or comments: 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 Comments on Physical Exam findings: Page 4 of 5 Do not re-use this form after 11/14/2017
Assessment Blood & body fluid precautions knowledge adequate Certification Examinations Qualified Not Qualified Pending HEALTH CARE WORKERS (HCWS) (719) Disposition and Follow-up Released from Occupational Health Clinic Follow-up with PCM on or in Return for follow-up exams: HEALTH CARE WORKERS (HCWS) in 1 year. 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