Form Navmed 6120/8 Periodic Health Assessment (Civilian Provider) Page 2
Download a blank fillable Form Navmed 6120/8 Periodic Health Assessment (Civilian Provider) in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Navmed 6120/8 Periodic Health Assessment (Civilian Provider) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
28. ASSESSMENT
Excellent
Good
Fair
Poor
GENERAL HEALTH
_____________________________________________________________________________________
Examiner’s Comments:
____________________________________________________________________________________________________
9. PLAN
a. LABS ORDERED:
LIPID PANEL
THYROID
CBC
BMP
CMP
OTHER
________________________________
b. CLINICAL PREVENTIVE SERVICES RECOMMENDED:
Colonoscopy
Mammogram
Pap Test
Prostate
Hearing Assessment
Other
_____________________________________________________________________________________________
c. PREVENTIVE/HEALTHY LIFESTYLE COUNSELING:
Smoking Cessation
Weight Reduction
Stress Management
d. OTHER REFERRALS
____________________________________________________________________________________
10. PROVIDER’S NAME (Last, First, Middle Initial)
11. PROVIDER’S ADDRESS (Street, City, State, 9-digit Zip Code)
12. PROVIDER’S TELEPHONE NUMBER (Include Area Code)
13. PROVIDER’S SIGNATURE/STATE LICENSE NUMBER
14. DATE OF EXAMINATION (DD/MM/YYYY)
15. MILITARY USE BELOW THIS LINE
______________________________
a. Date Fleet and Marine Corps Health Risk Assessment completed (DD/MM/YYYY):
_______________________________
b. Date counseling completed (DD/MM/YYYY):
____________________________________
________________________
c. Immunizations provided this date:
Date HIV drawn (<2yrs):
d. Medication prescriptions reviewed: YES / NO / NA
e. Corrective lenses prescription reviewed: YES / NO / NA
Dental Class I
II
III
IV
_______________________________
f. Date dental exam completed (DD/MM/YYYY):
Prescription glasses (2 pair)
Gas Mask Inserts (1 pair)
Contacts
g. Required medical equipment:
Hearing Aids
Medical Alert Tag (Red Dog Tags)
Yes
No
h. Deployment History:
Deployed since the previous PHA?
Yes
No
Post-Deployment Health Assessment (DD2796) in record?
Yes
No
Post-Deployment Health Re-Assessment (DD2900) in record?
Yes
No
Any unresolved deployment-related issues or health concerns?
Member fit for full duty
Member placed in TNPQ / TNDQ / MRR / LOD status for:
______________________________________________________
MEMBER’S SIGNATURE_________________________________________________________
DATE____________________________________
PROVIDER’S SIGNATURE________________________________________________________
DATE____________________________________
COUNSELOR/MDR’S SIGNATURE_________________________________________________
DATE____________________________________
NAVMED 6120/8 (08-2013)
Page 2 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Urgent Behavioral Health Screening Form To Obtain Specialty Mental Health Assessment Template
Medical
Form Hcpc-eml - Certification Of Health Care Provider For Employee's Serious Health Condition (family And Medical Leave Act) - 2015
Business
Form Hcpc-fml - Certification Of Health Care Provider For Family Member's Serious Health Condition (family And Medical Leave Act)
Business
Form Fml 501 - Certification Of Health Care Provider For Employee's Serious Health Condition (family And Medical Leave Act)
Business
Form Fml 501 - Certification Of Health Care Provider For Family Member's Serious Health Condition (family And Medical Leave Act)
Business
Related Categories
Parent category: Business