Modified Screening For Overseas Assignment And Or Sea Duty Health
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1Modified Screening For:
U.S. DEPARTMENT OF
HOMELAND SECURITY
Overseas Assignment and/or Sea Duty Health Screening
U.S. COAST GUARD
This form is subject to the Privacy Act Statement of 1974
CG-6100 Rev. 04-09
A. EXAMINEE DATA
LAST NAME - FIRST NAME - MIDDLE INITIAL
RATE/RANK
SOCIAL SECURITY NUMBER
UNIT
EXAMINING FACILITY
PURPOSE OF SCREENING
TRANSFER/DEPLOYMENT LOCATION
DATE
B. HEALTH HISTORY (completed by examinee)
1. Would you say your health in general is:
Excellent
Good
Fair
Poor
2. Do you have any medical or dental problems or concerns?
No
Yes
3. Do you have any health related duty limitations?
No
Yes
4. Could you be pregnant? (females request HCG if needed)
N/A
Unknown
No
Yes
5. Are you taking prescription medications? (request refills if needed)
No
Yes
6. During the past year, have you sought or required counseling or mental health care?
No
Yes
7. Explain any "fair, poor, yes, or unknown" responses:
8. Have you been hospitalized since your last Periodic Health Assessment (PHA)?
Yes
No
If (Yes) explain.
I certify that the responses above are true: (signature of examinee)
C. PERIODIC HEALTH ASSESSMENT (PHA) REVIEW (current approved PHA required)
9. Date of most recent PHA:
10. Status of recommendations or further specialist examination:
11. Summary of significant health history since last PHA:
D. HEALTH RECORD & INDIVIDUAL MEDICAL READINESS REVIEW
12. Have routine gynecologic (pap) examinations been completed in the past year? (females)
N/A
No
Yes
13. Does examinee have two pair of glasses? (if required)
N/A
No
Yes
14. Does deployable member have a gas mask insert? (if required)
N/A
No
Yes
15. Has DNA sampling been completed and documented? (once per career)
No
Yes
16. Has G-6PD screening been completed and documented? (once per career)
No
Yes
17. Are immunizations up-to-date and meet requirements for destination?
No
Yes
18. Has an HIV test been drawn (with negative results) in the past 6 months? (foreign country PCS only)
N/A
No
Yes
19. Has a baseline TST been completed and documented?
No
Yes
20. Have specific force health protection requirements been met (e.g. malaria chemoprophylaxis)?
N/A
No
Yes
21. Has a Type 2 dental examination been completed in the past year and is examinee “Class 1 or 2”?
No
Yes
22. Explain any "no" answers: _____________________________________________________________________________________________
Contact the Centers for Disease Control and Prevention at and the National Center for Medical Intelligence at
https://
E. SIGNATURE (Medical and Dental Provider or IDHS)
Medical Provider/IDHS signature/stamp: ___________________________________________________
Date:_______________________
Dental Provider/IDHS signature/stamp: ____________________________________________________
Date:_______________________
F. APPROVAL/DISAPPROVAL (Clinic Administrator)
Approved
Reviewing/approving authority: ____________________________________________________________
Disapproved
U.S. Dept. of Homeland Security, USCG, CG-6100, Rev. 04-09
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