Af Form 4321 PDF Details

The Reserve Component Health Risk Assessment (RCHRA), denoted by AF Form 4321, serves a critical role in maintaining the health and readiness of military Reserve Component personnel. Governed under the authority of 10 U.S.C., 8013 and implemented by Air Force Instruction 48-123, this form collects personal health information with the purpose of evaluating an individual's capability to undertake routine fitness testing, assess their deployment readiness, and contribute to the overall deployment readiness of the Reserve Component. The form incorporates a detailed health status questionnaire that requires members to disclose information about their general health, medical history, medication use, and personal health habits, such as tobacco and alcohol use. Furthermore, it includes specific questions aimed at identifying any conditions that might interfere with duty performance or deployment capability, thus ensuring the safety and effectiveness of military operations. The use of this form is also a proactive measure to identify any potential health risks amongst Reserve personnel early, requiring the disclosure of information under the Privacy Act of 1974, with stipulations for confidentiality and parameters for routine use within the Department of Defense systems. In essence, AF Form 4321 embodies a comprehensive approach to safeguarding the health of Reserve Component members, emphasizing the importance of accurate and timely health information for maintaining military readiness.

QuestionAnswer
Form NameAf Form 4321
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesform reserve risk, af form health, af 2005, known form 4321

Form Preview Example

Reserve Component Health Risk Assessment (RCHRA)

(This form is subject to the privacy Act of 1974 – Use Blanket PAS – DD Form 2005)

AUTHORITY: 10 U.S.C., 8013, as implemented by Air Force Instruction 48-123.

PURPOSE: To collect personal information from military Reserve Component (RC) personnel to assess their ability to perform routine fitness testing, their individual deployment readiness, and overall RC deployment readiness.

ROUTINE USE(S): To assess the safety of your performing routine fitness testing. To screen for conditions that may interfere with your ability to deploy and meet mission requirements. To collate data on overall RC capability to deploy and meet mission requirements. In addition to those disclosures generally permitted under 5 USC 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside DoD as a routine use pursuant to 5 USC 552a(b)(3) as follows: The Department of the Air Force “Blanket Routine Uses” set forth at the beginning of the Air Force’s compilation of systems of records notices apply to this system. This information will be kept in your medical record and summary results will be provided to you upon completion of the Reserve Component Periodic Health Assessment (RCPHA).

DISCLOSURE: Disclosure of this information is required by Title 10,Chapter 51, Section 1004 of the United States Code. Giving false information concerning current health status is a punishable offense and can result in administrative action. IAW AFI 48-123, paragraph 14.4.2, each member is responsible for promptly reporting a disease, injury, operative procedure or hospitalization not previously reported to his or her commander or supervisor.

Personnel Data

Name/Rank

SSN

Age

Date of Birth

Gender

Home Street Address

City

State

Zip Code

Unit

Duty Section

Base

Duty AFSC

ASC

Primary Email Address

Home Phone

Duty Phone

Civilian Occupation

 

Active (AGR)

 

 

Traditional

 

 

 

Individual (IMA)

 

 

Air Reserve

 

Other Specify

 

 

Guard/Reserve

 

 

Reservist/Guardsman

 

Mobilization Augmentee

 

 

Technician

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Traditional ARC: How many days have you performed military duty this year (excluding IDT)?

 

 

 

 

 

Days

 

 

 

 

 

 

 

 

 

 

 

 

Are you a family member of an active duty military member entitled to care through military channels?

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

Racial Background

 

 

 

 

 

 

 

 

 

 

 

 

American Indian/Alaska Native

 

Asian/Oriental

 

 

 

Black, Hispanic

 

 

 

 

 

 

 

 

Black, Non-Hispanic

 

 

Pacific Islander

 

 

 

White Hispanic

 

 

 

 

 

 

 

 

White, Non-Hispanic

 

 

Other (Specify)

 

 

 

 

 

 

 

 

 

 

Health Status Questionnaire– Instructions

Mark the appropriate response to each number question and sign the form after reading it carefully. Continue on the reverse side or attach comments or documentation if necessary. Positive responses which are not fully explained or which may effect your medical qualifications for continued military duty will require an interview and further documentation. You may also be required to provide supporting civilian medical and dental documentation for inclusion in your medical records.

NOTE: This information is for official and medically–confidential use only and will not be released to unauthorized persons.

1. Overall Self-Assessment of Health is

Excellent

Very Good

Good

Fair

Poor

2.Are you on a renewable flying or worldwide duty waiver for any medical reason?

3.Do you have any allergies to medications, foods, or airborne substances?

List all known allergies:

Yes No

Yes No

AF FORM 4321, 20030221 (EF-V1)

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4.(a) Do you regularly take any prescription medication(s)?

(b)Do you regularly take any over the counter medication(s)?

(c)Do you regularly take any dietary supplement(s)?

Yes No

Yes

NO

 

Yes

No

 

Medication(s) Name and why taken

5. During the last year have you taken medication or seen a health care provider for any of the following conditions?

Chest pain/angina

 

Yes

 

No

Shortness of breath

 

Yes

 

No

Anxiety/depression

 

 

Yes

 

No

Inflammatory bowel disease

 

 

 

 

Yes

 

No

Seizure Disorder

 

 

 

 

Yes

 

No

If you require medications for any of the above, have the medications been listed in block # 5.

 

 

 

 

Yes

 

No

Does the use of these medications control your symptoms?

(If No please explain below)

 

 

N/A

 

Yes

 

No

6.

During the last year have you been told that you have high blood pressure?

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

7.

Since your last AF Form 895, RCPHA, or Physical Examination have you had chest pains, pressure, or discomfort either

 

 

 

 

 

with physical activity or when at rest?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

8.

Have you ever had irregular heartbeats that have concerned you?

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

9.

Have you ever had a heart attack?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

10.

Have you had a heart operation (bypass, angioplasty, etc.)?

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

11.

Is there a family history of heart attack in a parent, sibling, aunt or uncle before the age of 55?

 

 

 

 

 

Yes

 

 

No

12.

Have you been told you have high blood sugar or diabetes? How is it controlled? (Check all that apply.)

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

Diet/Exercise

 

 

Oral

 

 

 

Other (Explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insulin

 

control

 

 

Medication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.

Have you been told you have problems with blood cholesterol?

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

14.

Do you use any tobacco products?

If no, skip to question 15.

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

Type- (check all that apply):

 

 

Pipe

 

 

Cigar

 

 

Smokeless

 

 

Cigarettes

 

 

 

 

 

How many packs of cigarettes per day?

 

 

 

Less than one

 

 

One

 

 

Two

 

Three or more

 

How many years have you been using tobacco products?

 

 

 

Less than one

 

 

One-Five

 

 

Six-Ten

 

More than Ten

 

AF FORM 4321, 20030221 (EF-V1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Date

Name/Rank

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15.

Do you ever experience shortness of breath at rest, walking or with only moderate exertion?

 

 

 

 

Yes

 

No

16.

Have you ever been told you have asthma, bronchospasm, or reactive airway disease?

 

 

 

 

Yes

 

No

17.

Do you engage in a program of regular aerobic physical fitness 20 minutes 3 times per week?

 

 

 

 

Yes

 

No

 

 

 

Light Exercise

 

 

 

 

 

Moderate Exercise

 

 

 

 

Heavy Exercise

 

 

 

18.

Do you have a physical condition that prevents you from brisk walking or running for 1 to 3 miles?

 

 

 

 

Yes

 

No

19.

Has your treating physician placed you on restricted activity?

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

If yes, explain (include length of time and time of year restrictions apply if known)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20.

Do you have any bone, joint, or muscle problems that prevent regular exercise or become bothersome during exercise?

 

Yes

 

No

21.

Are you on any medications for depression, attention deficit, hyperactivity disorder or any other psychiatric condition?

 

Yes

 

No

 

 

 

a. Do you consume alcoholic beverages?

If no, skip to question 22.

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

b. Have you ever felt you ought to cut down on your drinking?

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

c. Have people annoyed you by criticizing your drinking?

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

d. Have you ever felt bad or guilty about your drinking?

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

e. Have you ever had a drink first thing in the morning (eye opener) to steady your nerves or get rid of a hangover?

 

Yes

 

No

22.

Is there a history of cancer in your family?

Check all that apply. [] Breast

[] Prostate/Testicular

[] Colon

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[] Leukemia

[] Other (Explain)

 

 

 

 

 

 

No

23.

Do you wear prescription glasses or contact lenses? Check all that apply below.

 

 

 

 

Yes

 

No

 

 

 

Blurred Vision

 

 

Double Vision

 

 

 

Blind Spots

 

 

Night Blindness

 

 

 

 

 

Glare

 

 

 

 

 

 

 

Glaucoma

 

 

 

 

 

 

 

Glasses more than 2 years old

 

 

 

24.

Have you had any of the following types of eye surgery (check all that apply)?

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

RK

 

 

PRK

 

LASIK

 

Implants

 

 

Other Specify:

 

 

 

 

 

 

 

25.

Have you gained or lost more than 15 pounds in the past year that cannot be explained by change in diet and exercise?

 

Yes

 

No

26.

Have you noticed blood in your stool or significant changes in your bowel habits?

 

 

 

 

Yes

 

No

27.

Have you been advised to eat a special diet?

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

28.

During the past year have you missed more than 7 days from work due to illness or injury?

 

 

 

 

Yes

 

No

29.

Do you have a non-military job or hobby which exposes you to loud noise?

 

 

 

 

 

 

 

 

 

Yes

 

No

30.

Do you have a non-military job or hobby which exposes you to hazardous chemicals?

 

 

 

 

Yes

 

No

AF FORM 4321, 20030221 (EF-V1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Name and/or type of chemical(s)?

31.

Do you use hearing aid(s)?

 

 

 

 

 

 

 

 

 

 

Yes

 

No

32.

Do you routinely forget to wear proper protective gear for sports, hobbies, or work (e.g., helmets, goggles, ear plugs,

 

 

 

 

gloves, etc.)?

 

 

 

 

 

 

 

 

 

 

Yes

 

No

33.

Do you routinely forget to fasten your seat belt?

 

 

 

 

 

Yes

 

No

34.

Have you seen a health care provider during this past year?

 

 

 

 

 

Yes

 

No

If yes how many visits:

 

One - Two

 

 

Three - Six

 

Seven - Ten

 

More than Ten

 

 

35.

Excluding pregnancy have you been a patient in the hospital overnight/or had any outpatient surgical procedure or been

 

 

 

 

administered intravenous medication in the hospital during the past year?

 

 

 

 

 

Yes

 

No

36.

Have you been treated for any other medical conditions since you completed your last RCPHA or

 

 

 

 

 

 

AF Form 895? Please list conditions below.

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Females Only Complete Blocks 37 – 41

 

 

 

 

 

 

37.

Are you pregnant?

 

 

 

 

 

 

 

 

 

 

Yes

 

No

38.

Was your last PAP Smear abnormal?

 

 

 

 

 

 

 

 

Yes

 

No

39.

Have you ever had an abnormal breast lump or mammogram?

 

 

 

 

 

Yes

 

No

40.

Do you perform self-breast examination (SBE) at least monthly?

 

 

 

 

 

Yes

 

No

41.

If no longer having menstrual periods or had a total hysterectomy, have you been advised regarding osteoporosis

 

 

 

 

prevention?

 

 

 

 

 

 

 

 

 

 

Yes

 

No

I understand that disclosure of this information is required by Title 10,Chapter 51, Section 1004 of the United States Code. Giving false information concerning current health status is a punishable offense and can result in administrative action. IAW AFI 48-123, paragraph 14.4.2, each member is responsible for promptly reporting a disease, injury, operative procedure or hospitalization not previously reported to his or her commander or supervisor.

Typed or Printed Name Examinee

Signature

Date

 

 

 

Notes:

 

 

 

 

 

Typed or Printed Name Physician or Examiner

Signature

Date

 

 

 

AF FORM 4321, 20030221 (EF-V1)

 

Page 4

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