MANUAL OF NAVAL PREVENTIVE MEDICINE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
HEALTH CARD PHYSICAL EXAMINATION (MEDICAL SCREENING)
1. Are you suffering from any of the following:
e) Sore throat with fever?
2. Lesions containing pus on the hand, wrist or an exposed body part?
(such as boils and infected wounds, however small)
1. Have you ever been diagnosed as being ill with typhoid fever (Salmonella typhi), shigellosis (Shigella spp.),
Escherichia coli 0157:H7 infection (E. coli 0157:H7), or hepatitis A (hepatitis A virus)? YES
If you have, what was the date of the diagnosis?
HIGH RISK CONDITIONS:
1. Have you been exposed to or suspected of causing a confirmed outbreak of typhoid fever, shigellosis,
E. coli 0157:H7 infection, or hepatitis A?
2. Do you live in the same household as a person diagnosed with typhoid fever, shigellosis, hepatitis A, or
illness due to E. coli 0157:H7?
3. Do you have a household member attending or working in a setting where there is a confirmed
outbreak of typhoid fever, shigellosis, E. coli 0157:H7 infection, or hepatits A?
4. Have you traveled outside the United States within the last 50 days?
¨ Not Qualified
Health Care Provider Signature
PATIENT'S IDENTIFICATION (USE THIS SPACE FOR MECHANICAL IMPRINT)
PATIENT'S NAME (Last, First, Middle initial)
RELATIONSHIP TO SPONSOR
CHRONOLOGICAL RECORD OF MEDICAL CARE
AUTOMATED STANDARD FORM 600 (Rev: 12/97)