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!
Question | Answer |
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Form Name | Navmed 6120 4 Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | health pha record, 6120 4, periodical health assessment, navmed 6120 |
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 |
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Vital Signs noted. Remarkable for: |
None |
Other: |
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Visual Acuity: OD: |
OS: |
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(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?
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 |
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Health Risk Assessment: Completed and reviewed? |
Yes |
No |
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Health Risk Assessment Level: |
High |
Med |
Low |
Cardiovascular Screening (Framingham
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
PATIENT'S NAME (Last, First, Middle Initial) |
SEX |
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SSN / IDENTIFICATION NO. |
STATUS |
RANK/GRADE |
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RECORDS MAINTAINED AT |
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DATE OF BIRTH |
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NAVMED 6120/4 (Rev. 03/2008)
PERIODIC HEALTH ASSESSMENT (PHA) (Continued)
Duty Status Assessment |
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On Limited Duty (LIMDU) |
Yes |
No |
NA |
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Comments: |
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Medical Board |
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Yes |
No |
NA |
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Comments: |
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TNPQ |
TNDQ |
NPQ |
LOD |
NA |
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Comments: |
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P: PLAN / P: PREVENTION |
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1. |
Updated DD 2766 Sections: |
1 |
2 |
3 |
4 |
5 |
6 |
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2. |
Health counseling performed and documented on the DD 2766: |
Yes |
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3. |
Labs ordered for the following: |
Blood Type and RH |
G6PD |
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Others as required by geographic, occupation, or ISIC |
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Electronic verification complete: |
Yes |
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No |
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7
No
HIV
8
9
DNA
10
11
Lipids
4. Immunizations ordered for the following: |
MMR |
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Tdap (1 time booster) or |
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Td |
IPV Influenza |
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Hep A #1 #2 |
Hep B #1 |
#2 |
#3 (required for all new recruits) TWINRIX® may be used (3 shots required) |
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Other immunizations: |
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Electronic verification complete: |
Yes |
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No |
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5. Tuberculosis Screening:
PPD |
Placement: |
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Results: |
6. Clinical Preventive Services recommended: |
Pap |
Chlamydia Mammogram |
Colorectal |
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Clinical Breast Exam |
Testicular Exam |
Prostate |
Cholesterol |
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Other: |
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7. |
Referred to Dental for: |
Annual |
Dental Class 3 |
Dental Class 4 |
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8. |
Referred to PCM for: |
Physical Fitness Clearance |
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Current Medications / Supplements |
Chronic Medical Conditions |
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Other: |
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Bitewings |
Panograph |
Current Illness / Injury
9. Referred for |
Preventive / Healthy Lifestyle Counseling: |
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Tobacco |
Use |
Physical Activity |
Safety |
Sexuality |
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Other |
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Alcohol Use
Dental Care
Nutrition
Mental Health
10. Other indicated referrals:
Audiology |
Optometry |
Chaplain |
DAPA |
Other: |
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Behavioral Health
FFSC
OB / GYN Semper Fit
Dietician |
OCC Health |
Weight Management |
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11. Member readiness reviewed |
Yes |
No and updated in approved electronic data system |
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Member is fully medically ready and requires no |
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: |
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Date: |
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HM / MDR Signature: |
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Date: |
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Provider Signature: |
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Date: |
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NAVMED 6120/4 (Rev. 03/2008)