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Physical Examination Standard being Reviewed
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Provider (Examiner/Reviewer) Name
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Additional Persons or Translators Present
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Home of Record
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Languages Spoken:
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Occupation
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Employer
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Emergency Contact Name & Relationship:
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Emergency Contact #:
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Official Documents Uploaded
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Job Description Reviewed
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Vaccinations History
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Up To Date Vaccines per Personal Account
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Patient has visual proof of all vaccines
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Patient/employee doesnt have visual proof of all vaccines but attests to having the vaccines
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Additional Notes (Free Text)
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Current/Past Medical History
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No Medical & Surgical History
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Current/Previous Medical & Surgical History
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Social History (Tob, ETOH, Illicits)
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NORMAL TB Assessment form
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ABNORMAL TB assessment form
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Medication & Allergies
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Taking NO regular medications
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Medications (free text)
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No Known Allergies
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Allergies (meds, food, environmental)
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Has Enough Medication(s) for Deployment
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Medication Supply for Deployment (free text)
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Malaria Prophylaxis
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Requires Malaria Prophylaxis for Current/Upcoming Project
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Person is currently on Malaria Prophylaxis
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Malaria Prophylaxis Medication
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Additional Comments (Free Text)
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Physical Exam
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Physical Exam Performed by Another Provider: Documents Reviewed
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Vital Signs & BMI
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General
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Dermatological
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HEENT
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Nervous System
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Cardiovascular
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Genitourinary- MALES
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Respiratory
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Genitourinary/Breasts- FEMALES
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Gastrointestinal
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Blood/Lymphatic
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Musculoskeletal
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Mental Health
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Additional Component to Physical Exam Done
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Physical Exam Abnormality Comments
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Laboratory, Testing, and Imaging
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Select Labs Reviewed
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Laboratory Review Abnormality Comments
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Chest Xray Results Reviewed and Within Normal Limits
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CXR Review Comments
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ECG Reviewed and Withing Normal Limits
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ECG Review Comments
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Spirometry Reviewed and Within Normal Limits
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Spirometry Results Review Comments
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Audiometry Reviewed and Within Normal Limits
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Audiometry Results Review Comments
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Additional Examinations Reviewed
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ASCVD Risk Calculator (%)
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ASCVD Risk Calculator Performed
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ASCVD Risk Calculator (%)
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Additional Notes
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Change in Health Status Survey
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Indicated YES or NO Change in Health Status
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Additional Notes
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Referral/Request
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Referral/Request Notes
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Determination Pending
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MEDICAL HOLD
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Medical Hold Reason(s)
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Additional Medical Hold Reason(s)(Free Text)
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Medical Hold Plan (free text)
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FIT FOR DUTY DETERMINATION
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Temporary Fit For Duty (with info provided)
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Fit For Duty: 3 months
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Fit For Duty: 6 months
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Fit For Duty: 1 year
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Fit For Duty: 2 years
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Fit For Duty (free text)
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Additional Comments (Free Text)
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CERTIFICATION FAILURE
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Additional Comments (Free Text)
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