Navmed 6120 4 Form PDF Details

Are you in the U.S. Navy and looking for information about Navmed 6120/4? It can be hard to keep track of all the necessary paperwork throughout your military career, especially forms that need to be filled out on an annual basis like Navmed 6120/4. In this blog post, we will provide an overview of what is included on the form as well as helpful tips for getting it completed quickly and easily so you can focus on other important tasks during your service. Read on to learn more!

QuestionAnswer
Form NameNavmed 6120 4 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshealth pha record, 6120 4, periodical health assessment, navmed 6120

Form Preview Example

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

 

 

 

NAVMED 6120/4 (Rev. 03/2008)

PERIODIC HEALTH ASSESSMENT (PHA) (Continued)

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

4. Immunizations ordered for the following:

MMR

 

Tdap (1 time booster) or

 

Td

IPV Influenza

Hep A #1 #2

Hep B #1

#2

#3 (required for all new recruits) TWINRIX® may be used (3 shots required)

Other immunizations:

 

 

 

 

 

 

 

 

 

 

 

Electronic verification complete:

Yes

 

No

 

 

 

 

 

5. Tuberculosis Screening:

PPD

Placement:

 

Results:

6. Clinical Preventive Services recommended:

Pap

Chlamydia Mammogram

Colorectal

Clinical Breast Exam

Testicular Exam

Prostate

Cholesterol

 

Other:

 

 

 

 

 

 

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

12. Additional Comments:

13.Member informed that completion of recommended tests / immunizations / screenings is to be performed within the next 30 days, and he/she is personally responsible for maintaining IMR. Service Member received health risk prevention / healthy lifestyle counseling and voiced understanding.

Member Signature:

 

 

Date:

HM / MDR Signature:

 

 

Date:

Provider Signature:

 

 

Date:

 

 

 

 

 

NAVMED 6120/4 (Rev. 03/2008)