Navmed 6120 4 Form – Fill Out and Use This PDF

DATE:

SCREENING:

Height: (inches)

Weight (pounds)

BMI:

Temperature:

PERIODIC HEALTH ASSESSMENT (PHA)

S: SUBJECTIVE

____ year old ( ) male ( ) female reports for an annual PHA which includes record review/verification,

assessment and counseling of health risk factors, clinical preventive services, deployment health history, and individual medical readiness (IMR) assessment.

Allergies (Medication and other): See Block 1 on DD 2766

Chronic Illnesses: See Block 2 on DD 2766

Medications (Rx / OTC / herbals / supplements / performance enhancers): See Block 3 on DD 2766

Hospitalizations/Surgeries since last PHA: See Block 4 on DD 2766

Family History: See Block 6 on DD 2766

Occupational History: See Block 8 on DD 2766

O: OBJECTIVE
Vital Signs noted. Remarkable for:	None	Other:
Visual Acuity: OD:	OS:		(Consult if worse than 20/40, no contacts)

Physical examination is otherwise deferred.

deferred Pulse:

Respirations:

Health Record

Dental Readiness

Dental Classification

Immunization Record

Lab/Path Results

Clinical Prev. Services

Occupational Health

Hearing Assessment

Reviewed

Reviewed

1

Reviewed

Reviewed

Reviewed

Reviewed

Reviewed

Not Available

Not Available

2

Not Available

Not Available

Not Available

Not Available

Not Available

Remarkable for: See Plan

3 4

See Plan See Plan See Plan See Plan See Plan

deferred

Blood Pressure:

MEDICAL

EQUIPMENT:

Prescription Lenses (two pairs)

Y N NA

Deployment Health: See DD 2766 Deployed since previous PHA?

Post-Deployment Health Assessment (DD 2796) in record? Post-Deployment Health Reassessment (DD 2900) in record? Any unresolved deployment-related issues or health concerns? Comments:

Yes	No
Yes	No
Yes	No
Yes	No

Ballistic Eyewear

Y N NA

Gas Mask Inserts

Y N NA

Medical Alert Tags

Y N NA

A: ASSESSMENT
Health Risk Assessment: Completed and reviewed?	Yes	No
Health Risk Assessment Level:	High	Med	Low

Cardiovascular Screening (Framingham 10-year risk for Event/Death):

Pain Assessment (zero pain to severe): 0 1 2 3 4 5 6 7 8 9 10 Location:

Any other current health concerns?

PATIENT'S IDENTIFICATION

(Use this space for mechanical imprint, telephone number, and e-mail address for follow-up):

PATIENT'S NAME (Last, First, Middle Initial)		SEX
SSN / IDENTIFICATION NO.	STATUS	RANK/GRADE
RECORDS MAINTAINED AT		DATE OF BIRTH

Duty Status Assessment
On Limited Duty (LIMDU)			Yes	No	NA		Comments:
Medical Board			Yes	No	NA		Comments:
	TNPQ	TNDQ	NPQ	LOD	NA		Comments:
P: PLAN / P: PREVENTION
1.	Updated DD 2766 Sections:			1	2	3	4	5	6
2.	Health counseling performed and documented on the DD 2766:							Yes
3.	Labs ordered for the following:			Blood Type and RH				G6PD
	Others as required by geographic, occupation, or ISIC
	Electronic verification complete:			Yes		No

7

No

HIV

8

9

DNA

10

11

Lipids

5. Tuberculosis Screening:

PPD

Placement:

Results:

7.	Referred to Dental for:	Annual T-2 Dental Exam		Dental Class 3	Dental Class 4
8.	Referred to PCM for:	Physical Fitness Clearance		Deployment-Related Condition
	Current Medications / Supplements		Chronic Medical Conditions
	Other:

Bitewings

Panograph

Current Illness / Injury

9. Referred for	Preventive / Healthy Lifestyle Counseling:
Tobacco	Use	Physical Activity	Safety
Sexuality		Other

Alcohol Use

Dental Care

Nutrition

Mental Health

10. Other indicated referrals:

Audiology	Optometry
Chaplain	DAPA
Other:

Behavioral Health

FFSC

OB / GYN Semper Fit

Dietician	OCC Health
Weight Management

11. Member readiness reviewed	Yes	No and updated in approved electronic data system
Member is fully medically ready and requires no follow-up at this time: Yes			No

Yes

No