Va Form 0928c - National Veterans Summer Sports Clinic General Medical/physical Exam Form - 2012 Page 2

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GENERAL MEDICAL/PHYSICAL EXAM FORM - Page 2

PATIENT'S NAME

SOCIAL SECURITY NUMBER

(Last 4 digits only)

MEDICAL HISTORY - DO NOT SEND IN WITHOUT ALL OF THE FOLLOWING

1. Attach your recent H & P (history and physical) problem list with all medical and surgical history.

2. Attach recent (within last 6 months) EKG for any patient 40 years of age and older.

3. Attach list of current medications.

4. Attach discharge summary for any patient hospitalized during the last three (3) years.

ALLERGIES

DOES THE PATIENT HAVE DYSREFLEXIA?

YES

IF YES, EXPLAIN

DOES THE PATIENT HAVE ANTICOAGULATION

YES

IF YES, EXPLAIN

OR OXYGEN REQUIREMENTS?

YES

DOES THE PATIENT SMOKE?

YES

IF YES, DESCRIBE

ALCOHOL OR SUBSTANCE ABUSE?

CARDIOPULMONARY REVIEW OF SYSTEMS

YES

WAS DONE AND IS UNREMARKABLE

PHYSICAL EXAM (To be filled out completely by physician)

HEIGHT

WEIGHT

(inches)

(pounds)

PULSE

BLOOD PRESSURE

HEENT

CARDIAC

PULMONARY

ABDOMEN

EXTREMITIES

NEURO

Dear Clinician: Your patient is planning on participating in a vigorous outdoor summer sporting rehabilitation clinic. Examples of high-risk patients

are: a smoker who is overweight; brittle diabetics; patients with significant COPD or CHF; and patients that require close medical supervision.

High risk patients: those with potential sun exposure risks and possible hypothermia risks - these events will be outside in high sun and potential cold

water temperatures. Patients are admitted to this clinic based on your judgements about their current health status.

IF THEY REQUIRE HOSPITALIZATION FOR A PRE-EXISTING CONDITION, YOUR MEDICAL CENTER WILL BE LIABLE FOR

ANY CHARGES INCURRED OUTSIDE OF VA CARE. DO NOT SEND ANY PATIENT THAT IS CURRENTLY UNSTABLE OR

UNDERGOING EVALUATION FOR CLINICAL INSTABILITY.

If the patient's condition changes before the event, please contact Michal "Kalli" Hose, MD at the VA San Diego Healthcare System,

(858) 518-5056 or contact the Division of General Internal Medicine through operator at (858) 552-8585, e-mail MichalKalli.Hose@va.

gov.

PATIENT IS MEDICALLY FIT TO PARTICIPATE

PATIENT IS NOT MEDICALLY FIT TO PARTICIPATE

SIGNATURE AND TITLE OF EXAMING CLINICIAN

NAME OF EXAMING CLINICIAN (Please print)

HOSPITAL AND ADDRESS OF EXAMINING CLINICIAN