Health Card Physical Examination (Medical Screening)

MANUAL OF NAVAL PREVENTIVE MEDICINE

HEALTH RECORD

DATE

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

HEALTH CARD PHYSICAL EXAMINATION (MEDICAL SCREENING)

TODAY:

1. Are you suffering from any of the following:

a) Diarrhea?

YES

b) Fever?

YES

c) Vomiting?

YES

d) Jaundice?

YES

e) Sore throat with fever?

YES

2. Lesions containing pus on the hand, wrist or an exposed body part?

(such as boils and infected wounds, however small)

PAST:

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?

YES

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?

YES

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?

YES

4. Have you traveled outside the United States within the last 50 days?

YES

Qualified

Not Qualified

EXAM COMMENTS:

____________________________

_______________________________

Patient Signature

Health Care Provider Signature

PATIENT'S IDENTIFICATION (USE THIS SPACE FOR MECHANICAL IMPRINT)

RECORDS MAINTAINED

PATIENT'S NAME (Last, First, Middle initial)

SEX

RELATIONSHIP TO SPONSOR

STATUS

RANK/

GRADE

SPONSOR'S NAME

ORGANIZATION

DEPART./SERVICE

SSN/IDENTIFICATION NO.

DATE OF

BIRTH

CHRONOLOGICAL RECORD OF MEDICAL CARE

AUTOMATED STANDARD FORM 600 (Rev: 12/97)

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