FEDERAL OCCUPATIONAL HEALTH

MEDICAL SURVEILLANCE MANAGEMENT PROGRAM

HEALTH HISTORY AND PHYSICAL EXAMINATION FORM

Employee/Applicant: A comprehensive history is an important part of your medical record. Please:

►Read the Privacy Act Notice, below.

►Write your name and the current date, where indicated, on each page of this form.

►Answer all questions in Part I of this questionnaire (pages 2 – 5) by placing a check mark (√) or an X in the ap-
propriate spaces, or printing other information where requested (use black or blue ink).

►On page 5 in the Employee’s Comments space, Explain or discuss all of your Medical History or Review of
Systems responses where you have indicated that you have or have had any of the listed conditions or symp-
toms.

►Sign and Date the form where requested on page 5.

►Return the form to the clinic where your exam will be performed.

Privacy Act Statement

The collection and use of this information is authorized by 5 U.S.C. 7901 (Health Service Programs)
and 29 U.S.C. 657 (Occupational Health and Safety; Record Keeping). The information will become
part of your official Employee Medical File, and will be used to assist Federal Occupational Health in
carrying out its occupational health services responsibilities under one or more interagency
agreements with your employing agency, and for other official purposes and routine uses as
described in Privacy Act systems notice OPM/GOVT-10 (Employee Medical File System Records).
Providing the requested information is voluntary. Not providing the information may affect the
availability and quality of health services rendered to you, and may also affect the completeness of
information used by your agency in making determinations of medically-related employment
decisions.

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Employee Name: Date: FOH 5; Rev 1/2008
 FEDERAL OCCUPATIONAL HEALTH
MEDICAL SURVEILLANCE MANAGEMENT PROGRAM
HEALTH HISTORY AND PHYSICAL EXAMINATION FORM

Part I. Personal Information and Medical History

(to be completed by the employee/applicant before the examination
DO NOT LEAVE ANY SECTION BLANK; SPECIFY “N/A” (NOT APPLICABLE) IF APPROPRIATE

IDENTIFICATION Today’s Date Sex: Check One: Hispanic

Male Black (non-Hispanic) Asian
Female White (non-Hispanic) Pacific Islander
LAST NAME FIRST (No nicknames) MIDDLE American Indian/Alaskan Native

- - - -
SOCIAL SECURITY NO. BIRTHDATE PLACE OF BIRTH: Country State City

YOUR EMPLOYER AGENCY DIVISION ORGANIZATIONAL UNIT NAME OF SUPERVISOR SUPERVISOR’S TELEPHONE NO.

YOUR OFFICIAL OPM JOB TITLE AND JOB SERIES NUMBER YOUR WORK BUILDING/FACILITY YOUR WORK TELEPHONE NO.

YOUR HOME MAILING ADDRESS CITY, STATE ZIP HOME TELEPHONE NO.

II. MEDICATIONS V. MEDICAL HISTORY

Which of the following conditions have YOU ever had?
(Enter the year of diagnosis, if known, or place a √ if unknown.)
List ALL medications (including prescription, non-prescription, vitamins
and herbal preparations) you currently take: Allergies Specify:
Anemia Herniated disc
Asbestosis High blood pressure
Asthma Kidney disease
Broken bones Loss of consciousness
Cancer, specify type:
Chest surgery Mental Health Disorders
III. SOCIAL HISTORY Chronic bronchitis Migraines
Have you ever used tobacco? Yes No Claustrophobia Pneumonia
If "yes", When: Current Past - years since quitting? Collapsed lung Positive skin test for TB
Denture use Prostate problems
Type: Cigarettes Pipe/Cigar Diabetes Ruptured ear drum
Snuff/Chewing
Emphysema Seizures
Amount per day? For how many years?
Head Injury Silicosis
What is your average alcohol consumption in a week? drinks Heart attack Trouble smelling odors
(1 drink = 12 oz. beer, 1 glass wine or 1.5 oz liquor) Heart murmur Thyroid trouble
Hepatitis Other (specify):
If you drink alcohol, what is your usual pattern?
Weekdays Weekends Both

Are you right handed or left handed ? (check one)

IV. HOSPITALIZATIONS AND SURGERIES
YEAR REASON (continue on the back, if more space is needed)
VI. LEISURE ACTIVITIES
In which of the following hobbies/activities do you participate?

Painting Ceramics/Pottery Guns/hunting

Gardening Refinishing Stained glass

Auto/boat repair Power tool usage Other (specify below):

Do you use safety equipment when you engage in these activities? Yes No

DO NOT LEAVE ANY SECTION BLANK; SPECIFY “N/A” (NOT APPLICABLE) IF APPROPRIATE

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Employee Name: Date: FOH 5; Rev 1/2008
VII. PHYSICAL ACTIVITIES OR EXERCISE PROGRAM
Aerobic/Cardio Exercise: Light* Moderate* Heavy*
Activities: | Levels of Exercise defined as:
Frequency: (days per week) | Light/Mild exertion (2-3 METS) = negligible lifting, extended walking
Duration: (minutes/session) | (flat surface), extended standing, writing
Weight/Strength Exercise: Light* Moderate* Heavy* | Moderate exertion (4-5 METS) = lifting 10lbs (5 or more lifts/min)
Activities: , | fast walking (4mph), gardening/digging, pushing, pulling
Frequency: (days per week) | Heavy exertion (5-10 METS) = jogging (10 minute mile), chopping wood,
Duration: (minutes/session) | climbing hills, life-saving activities, firefighting

VIII. RESPIRATOR QUESTIONNAIRE (to be completed ONLY if you require a medical clearance for respirator use)
Respirator Use
Indicate the type of respirator you will use: Cartridge Air supply SCBA Dust Mask/Disposable/N-95
How often will you use a respirator? daily 1-4x/wk 1-4x/mo. 1-4x/yr.
Hours of use in a typical day: <2 2 -4 4 -6 >6
Usual effort while wearing respirator: light moderate heavy
Environmental conditions present during respirator use (check all that apply):
high altitude temperature extremes confined spaces post-fire/blast scenes
Do you wear contact lenses? yes no
Do you wear glasses? yes no
Have you had previous respirator use? yes no
Any difficulties with past respirator use? yes no
If yes, what kind of difficulties: Eye irritation Skin allergies/rashes Anxiety General weakness or fatigue
Any other problem that interferes with your use of a respirator: yes no If yes, what

Do you currently have any of the following symptoms of pulmonary or lung illness?

Shortness of breath: yes no

Shortness of breath when walking fast on level ground or walking up a slight hill or incline: yes no

Shortness of breath when walking with other people at an ordinary pace on level ground: yes no

Have to stop for breath when walking at your own pace on level ground: yes no

Shortness of breath when washing or dressing yourself: yes no

Shortness of breath that interferes with your job: yes no

Coughing that produces phlegm (thick sputum): yes no

Coughing that wakes you early in the morning: yes no

Coughing that occurs mostly when you are lying down: yes no

Coughing up blood in the last month: yes no

Wheezing: yes no

Wheezing that interferes with your job: yes no

Chest pain when you breathe deeply: yes no

Any other symptoms that you think may be related to lung: yes no
Have you ever had any of the following cardiovascular or heart symptoms?

Frequent pain or tightness in your chest: yes no

Pain or tightness in your chest during physical activity: yes no

Pain or tightness in your chest that interferes with your job: yes no

In the past two years, have you noticed your heart skipping or missing a beat: yes no

Heartburn or symptoms that are not related to eating: yes no

Any other symptoms that you think may be related to heart or circulation problems: yes no

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Employee Name: Date: FOH 5; Rev 1/2008
 DO NOT LEAVE ANY SECTION BLANK; SPECIFY “N/A” (NOT APPLICABLE) IF APPROPRIATE

RESPIRATOR QUESTIONNAIRE (continued)

Do you currently have any of the following musculoskeletal problems?

Weakness in any of your arms, hands, legs, or feet: yes no

Back pain: yes no

Difficulty fully moving your arms and legs: yes no

Pain or stiffness when you lean forward or backward at the waist: yes no

Difficulty fully moving your head up or down: yes no

Difficulty fully moving your head side to side: yes no

Difficulty bending at your knees: yes no

Difficulty squatting to the ground: yes no

Climbing a flight of stairs or a ladder carrying more than 25 lbs: yes no

Any other muscle or skeletal problem that interferes with using a respirator: yes no
IX. OCCUPATIONAL HISTORY
Briefly describe the activities of your current job:

How long have you been doing this type of work? years
Have you ever been off work more than a day because of work-related illness or injury? Yes No
If “yes”, specify
Have you ever changed jobs or duties due to health problems? Yes No
If “yes”, specify
Have you ever been placed on temporary restricted/limited duty with your current employer due to an illness or injury? Yes No
If “yes,” specify condition and year: ; Was it work-related? Yes No
What were the restrictions?
How long were / are they in effect?

If this is your FIRST FOH medical surveillance exam, list all outside or previous jobs, starting with the one before your current position:

Agency/Company Dates of Employment Job Duties Specific Hazards*

(from --- to)

* Hazards may include asbestos, chemicals, dusts, silica, beryllium, tungsten, cobalt, aluminum dust, coal, iron, tin, fumes, gases, radiation, vibration,
repetitive motion, intense light and loud noise, or any other recognized hazards.
* For any asbestos exposure, please indicate the year and place of first exposure, regardless of use of protective equipment:

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Employee Name: Date: FOH 5; Rev 1/2008
 DO NOT LEAVE ANY SECTION BLANK; SPECIFY “N/A” (NOT APPLICABLE) IF APPROPRIATE

XI. REVIEW OF SYSTEMS - Which of the following have been a problem for you in the last year?

General/Constitutional Heart/Lungs Skin/musculoskeletal

Fever, >100° Chest pain or pressure Rashes

Shivering/ chills Irregular heart beat Moles that changed in size or color

Generalized weakness Palpitations/skipped beats Muscle pain

Unexplained weight loss/gain New or changed cough Back pain

Excessive fatigue Coughing up blood Neck pain

Swollen glands Wheezing Weakness in arms/legs

Loss of appetite Shortness of breath Joint pain

Eyes Digestive System Genitourinary & Reproductive

Change in vision Nausea/vomiting Difficult or painful urination

Itching Diarrhea/Constipation (circle one or both ) Blood in urine

Tearing Yellow jaundice Difficulty having children

Rectal bleeding or black tarry stools
(Men Only)
Ears, Nose, Throat Neurologic/Psychiatric
Lump in Testicle
Difficulty hearing Headaches
Impotence
Ringing, buzzing Dizziness/passing out (circle one or both)
Sinus trouble (Women Only)
Depression
Sneezing/runny nose Irregular periods/spotting
Numbness or tingling
Nosebleeds Miscarriage or stillborn pregnancy
Excessive anxiety
Difficulty swallowing Breast lump/discharge
Insomnia / difficulty sleeping
Currently or possibly pregnant
Loss of memory

Employee’s Comments: [All of your positive responses in Part I, above, should be explained here.]

I certify that all of the information I have provided on this form is complete and accurate to the best of my knowledge, and that submitting information that is in-
complete, misleading, or untruthful may result in termination, criminal sanctions, or delays in processing this form for employment. Furthermore, consistent with
the Privacy Act Statement above, I authorize the release to my employing agency of all information contained on this examination form and all other forms gener-
ated as a direct result of my occupational health examination. The information will be used strictly for official purposes, as outlined above.

Signature of Applicant or Employee Date

Examiner’s Comments: [All of the Employee’s positive responses in Part I, above, should be commented upon here]:

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Employee Name: Date: FOH 5; Rev 1/2008
 Part II. Physical Examination
(to be completed by the examiner at the time of the examination)
DO NOT LEAVE ANY SECTION BLANK; SPECIFY “N/A” (NOT APPLICABLE) IF APPROPRIATE

Vital Signs: (in.) (lb.) Health Center Stamp

Height Weight Pulse Abdominal Girth BMI
/ (mm/Hg) / (mm/Hg)
Blood Pressure (#1) Blood Pressure (#2, if #1 was abnormal)

Year of last tetanus booster:

Year of last chest x-ray:
Has employee received Hepatitis B vaccine? Yes No
If “yes”, number of shots: 1 2 3 Year completed:
Tonometry: O.D: mm/Hg Monteux mm. induration Stool for neg x 3
O.S: (PPD) not done Occult positive
not done Blood not done
Best Vision: Testing method screening machine wall/hand held chart

Uncorrected With Correction: Contacts Glasses Comments:

Near: OU (both) 20/ Near: OU (both) 20/

OD (right) 20 OD (right) 20/
OS (left) 20/ OS (left) 20/
Far: OU (both) 20/ Far: OU (both) 20/
OD (right) 20/ OD (right) 20/
OS (left) 20/ OS (left) 20/

Peripheral vision (degrees)

Color Vision (test used: ) Depth Perception (test type and
Right Temporal Left Temporal Number correct: of tested seconds of arc)
Nasal Nasal
Total Total Can see red/green/yellow? Yes No

Physical Examination:
Not
Normal Abnormal Done Comment
General

Skin
Head
Eyes
Ears
Nose
Mouth
Throat
Neck
Thyroid
Lymph Nodes
Lungs
Breasts
Heart
Abdomen
Genitalilla
Rectal
Extremities
Arterial Pulses
Musculoskeletal
Neurological

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Employee Name: Date: FOH 5; Rev 1/2008
Mental Status
__________________________________________________
Cardiac Risk Factors:
Blood Pressure > 140/90 yes no

Fasting Glucose > 100 mg/dl yes no

Total Cholesterol > 200 mg/dl yes no

Family history of CVD in members < 55 yes no Obesity yes no

No regular exercise program yes no

Currently smoking or > pack/yr history yes no

FEDERAL OCCUPATIONAL HEALTH

MEDICAL HISTORY AND PHYSICAL EXAMINATION FORM
Part III. Examiner’s Summary
(to be completed by the examiner at the time of the examination)
DO NOT LEAVE ANY SECTION BLANK, SPECIFY “N/A” NOT APPLICABLE) IF APPROPRIATE

ASSESSMENT / REFERRAL PLAN

Abnormal Abnormal
Normal Clinically Insignificant Clinically Significant Not Applicable
Laboratory Results Were:
Electrocardiogram Was:
Physical Examination Was:
Specific Findings:
Not ---R e f e r r e d---
Comments: Referred Routine Urgent

1.

2.

3.

4.

5.

RECOMMENDATIONS / EDUCATION SUMMARY [Note: this is NOT a clearance summary; see Part V, Report to Employer]

THE FOLLOWING TOPICS AND RECOMMENDATIONS MARKED WITH A “√” WERE

DISCUSSED WITH THE EMPLOYEE:
All Results and Findings from this Examination

Protective Equipment, including: Preventive Health Measures:

Hearing Protection Smoking cessation
Safety glasses Dangers of smoking and asbestos exposure
Respirator use Reduce or stop alcohol consumption
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Employee Name: Date: FOH 5; Rev 1/2008
 Gloves/Skin protection Participate in regular cancer screening
Seat belts Self examination (breast, testicular)
Other Universal Precautions for BBP
Avoid sun exposure/Use sun block
Other

Name of Examiner (print) Examiner's signature Date

I have received a copy of the summary of my examination and understand the recommendations:

Employee Signature Date

FEDERAL OCCUPATIONAL HEALTH

MEDICAL SURVEILLANCE MANAGEMENT PROGRAM
MEDICAL HISTORY AND PHYSICAL EXAMINATION FORM
Part IV. Report to Employee
(to be completed by the reviewer)

NAME SSN

AGENCY EXAM DATE

Summary of occupational medicine consultant review:

Confidential report to the employee
The examiner who performed your medical surveillance exam should have discussed important findings of the exam, and made
suggestions to you about any medical follow-up that was needed. Your medical surveillance exam records also have been reviewed
by an occupational medicine consultant, and compared to results from prior medical surveillance exams when these were available.
This form provides the impressions of the medical consultant after reviewing your records, along with the consultant’s recommend-
ations for work modifications and suggestions for follow-up. This confidential information IS NOT shared with your supervisor.

1. Possible health effects from recent workplace exposures:

None noted

2. Health problems not caused by work, and which do not affect your ability to perform job duties safely and effi-
ciently:
None noted

3. Health problems not caused by work, but which may affect your ability to perform job duties safely and effi-
ciently:
None noted

4. Follow-up needed as part of the medical surveillance exam program (please send to the address given below)
None required

5. Other comments by the occupational medicine consultant

If you have questions, please call me at

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Employee Name: Date: FOH 5; Rev 1/2008
 Reviewer’s Name (Print) Reviewer’s Signature Date

Address

FEDERAL OCCUPATIONAL HEALTH

MEDICAL SURVEILLANCE MANAGEMENT PROGRAM
MEDICAL HISTORY AND PHYSICAL EXAMINATION FORM
Part V. Report to Employer
(to be completed by the reviewer)

NAME SSN

AGENCY EXAM DATE

Medical Opinion: (check all that apply)
The employee has been informed of the following medical opinion.
No medical findings were noted that indicate work-related injury/illness.
Where nonwork-related significant findings were noted, a referral has been made at the employee’s expense.
Medical findings support a work-related injury/illness or hazardous exposure, see recommendations below.
Medical findings or exposure history warrant a review of work activities, see recommendations below.
Decision deferred, additional documentation needed. Please provide the documentation listed below..
Work limitations recommended. (Specify limitations and re-evaluation date below).
Comments/Recommendations/Limitations:

Limitations should be reevaluated (Date)

Clearances:
Employee has been cleared for the routine duties outlined in the provided job description.
Motor Vehicle Clearance (DOT/DMV) Expires
Other. Specify Expires
(e.g.,, crane operator, diver, fire fighter, arduous duty)
Respirator Clearance (select one box □ and provide comments as appropriate)
This employee has been found to be physically able to use the following (check each [ ] that applies):
(see Respirator Medical Evaluation Questionnaire form for specific types and uses requiring clearance)
Single use, filter mask (four attachment points) Half-faced cartridge-type, negative pressure
Full-faced cartridge-type respirator, negative pressure Half-faced powered cartridge-type (PAPR)
Full-faced powered cartridge-type (PAPR) Self-contained breathing apparatus (SCBA)
Hood/helmet powered cartridge-type (PAPR) Half-faced/Full-faced/Hood/Helmet
(NOT positive pressure) (positive pressure airline respirator)
When wearing a respirator, the employee has been informed to limit activity level* to the following (check one ):
Mild Exertion Moderate Exertion Heavy Exertion (No specified limitations)
Other limitations needed (if any) when wearing a respirator:

This respirator clearance expires years from the date below. (If not marked, clearance expires in 1 year)
(circle one )
This employee has been found to be physically NOT able to use a respirator
There is insufficient information to make a determination at this time
The following additional tests, or medical information, will be required in order to make a determination regarding the
safe use of a respirator by this employee:

Reviewer’s Name (Print) Reviewer’s Signature Date

* Light/Mild exertion (2-3 METS)= negligible lifting, extended walking (flat surface), extended standing, writing
Moderate exertion (4-5 METS) = lifting 10lbs (5 or more lifts/min), fast walking (4mph), gardening/digging, pushing, pulling
Heavy exertion (5-10 METS) = jogging (10 minute mile), chopping wood, climbing hills, life-saving activities, firefightin
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Employee Name: Date: FOH 5; Rev 1/2008
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Employee Name: Date: FOH 5; Rev 1/2008