PERIODIC HEALTH ASSESSMENT (CIVILIAN PROVIDER)
Authority: 5 U.S.C. 301, Departmental Regulations; 10 U.S.C. 1095, Collection from Third Party Payers Act; 10 U.S.C. 5131 (as amended); 10 U.S.C.
5132; 44 U.S.C. 3101; 10 CFR part 20, Standards for Protection Against Radiation; and, E.O. 9397 (SSN). Purpose: This system is used by officials,
employees and contractors of the Department of the Navy (and members of the National Red Cross in naval medical treatment facilities) in the
performance of their official duties relating to the health and medical treatment of Navy and Marine Corps members; physical and psychological
qualifications and suitability of candidates for various programs; personnel assignment; law enforcement; dental readiness; member's physical fitness for
continued naval service. Routine uses: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or
information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3); When required by federal
statute, by executive order, or by treaty, medical record information will be disclosed to the individual, organization, or government agency, as necessary.
The DoD 'Blanket Routine Uses' that appear at the beginning of the Navy's compilation of system of records notices also apply to this system.
Disclosure: Voluntary. However, failure to provide the requested information may result in failure to receive required treatment and future benefits.
1. SERVICE MEMBER’S NAME (Last, First, Middle Initial)
2. SOCIAL SECURITY NUMBER
3. BRANCH OF SERVICE
4. UNIT OF ASSIGNMENT
5. UNIT ADDRESS
6. SUBJECTIVE
AGE
:______
____________________________________________________________________________
ALLERGIES (Medications and other):
CHRONIC ILLNESSES with date of onset:
________________________________________________________________________
MEDICATIONS/Supplements/Food/Rx/OTC (dosage and frequency
):_______________________________________________________
____________________________________________________________________________________________________
SURGERY/HOSPITALIZATIONS (Hx of all):
_______________________________________________________________________
____________________________________________________________________________________________________
ILLNESSES/INJURIES in last 12 months:
________________________________________________________________________
____________________________________________________________________________________________________
_______
_______
_______
_______
FAMILY RISK FACTORS (with date of onset): Heart Disease
High Blood Pressure
Diabetes
Cancer
________________________________________
Other- Please Specify
TOBACCO USE
__________________________________________________
NO
YES List quantity/frequency of current and past use
ALCOHOL USE
__________________________________________________________
NO
YES List quantity and frequency of use
7. OBJECTIVE
_____
_____
_____
_____
_____/_____
_____
VITAL SIGNS: Height (inches)
Weight (pounds)
BMI
Temp
Blood Pressure
Pulse
_____
Respirations
_______
_______
_______
_______
DISTANT VISUAL ACUITY: OS
OD
NEAR VISUAL ACUITY:
OS
OD
BODY SYSTEMS REVIEW
NORMAL
COMMENTS
YES / NO
a. General Appearance
YES / NO
b. HEENT
YES / NO
c. Lymph Glands
YES / NO
d. Cardiovascular (Auscultation)
Louder
Softer
No Change
If Murmur present
Standing makes it:
Louder
Softer
No Change
Squatting makes it:
Louder
Softer
No Change
Valsalva makes it:
e. Vascular
YES / NO
Carotid Pulses
YES / NO
Femoral Pulses
YES / NO
Pedal Pulses
YES / NO
f. Lungs: Auscultation/Percussion
YES / NO
g. Chest Contour
YES / NO
h. Skin
YES / NO
i. Abdomen and Viscera
YES / NO
j. Genito-urinary
YES / NO
k. Extremities
YES / NO
l. Spine, other musculoskeletal
YES / NO
m. Gross neurological (reflexes)
NAVMED 6120/8 (08-2013)
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