Army Medical Health Record Form: Chronological Record of Medical Care

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HEALTH RECORD I CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTOMS, DIAGNOSIS, TREATING ORGANIZATION (Sign each entry)
PRE -TRANSFER MEDICAL ASSESSMENT

**LIST ANY YES RESPONSES IN RAMARKS SECTION ON REVERSE SIDE OF FORM
AGE:
(Y) (N) (Y) (N)
( ) ( ) Allergies ( ) ( ) Recent illness/injury
( ) ( ) Dental Problems ( ) ( ) History of psychological problems (Date)
( ) ( ) HIV positive ( ) ( ) Chronic health problems or infectious diseases
( ) ( ) Previous Suicide Attempts (Date) ( ) ( ) Females only; Are you pregnant?
( ) ( ) History of alcohol abuse/treatment (Date) ( ) ( ) Current medications
( ) ( ) Current physical complaint(s) I.
I. Cough/Sputum Production 2.
2. Rash 3.
3. Diarrhea/Vomiting
4. Night sweats
5. Pain
6. Exposure to TB
7. Lice/Other infestation
8. Contagious disease in the past 12 months?
8. Other:
***** FOR MEDICAL PERSONNEL USE ONLY DETAINEE'S INITIALS ( )
HIVITUBERCULOSIS QU ESTIONAIRE
Do you have a history or, or do you presently have any ofthe following symptoms or conditions:
(Y) (N) (Y) (N)
( ) ( ) Persistent cough/shortness of breath ( ) ( ) Cough with blood and/or dry cougll
( ) ( ) Unexplained weight loss/diarrhea X 2 weeks ( ) ( ) Unexplained persistent fever
( ) ( ) Night Sweats ( ) ( ) Swollen glands/lymph nodes
( ) ( ) Prolonged fatigue or run -down feeling ( ) ( ) Loss of appetite and or whit e patches in mouth
( ) ( ) Recent exposure to someone with TB ( ) ( ) Past abnormal X -Ray (Date)
( ) ( ) Hepatitis B series completed ( ) ( ) Previous TB infection or treatment
( ) ( ) Stomach surgery, Kidney failu re, Blood disorders
( ) ( ) Scars, birthmarks, tattoos:
1. 4.
2. 5.
3. 6.
PATIENT'S IDENTIFICATION (Use this space for Mechanical imprint) RECORDS MAINTAINED AT:
PATIENT'S NAME (Last, First, Middle Initial) .1 SEX
RELATIONSHIP TO I STATUS I RANK/GRADESPONSOR DETAINEE ----_._-------------------
SPONSOR'S NAME 1 ORGANIZATION .----------------------------------------
DEPART/SERVICE JSSN/IDENTIFICA TION NO. 1 DOB

'734
DODDOA 026195
DATE
SYMPTOMS, DIAGNOSIS, 1REATING ORGANIZATION (Sign each entry) ---------------BELOW PORTION TO BE COMPLETED BY MEDICAL STAFF ---------------PHYSICAL APPEARANCE
Clean, well groomed (Y) (N) Tremors, sweating (Y) (N) Rashes, needle marks (Y) (N) Exposure to tuberculosis (Y) (N) Body deformities (Y) (N) Infestations (Y) (N) Cuts, bruises, lesions (Y) (N) Confinement Phys. Date:
VITAL SIGNS: Weight: Height: Temp: B/P: Pulse: Resp: PPD given: HIV drawn: RPR drawn:
Physical Exam: Within normal limits (Y) (N) See remarks for any (N) answers
Head ( ) ( )
Lungs/Chest ( ) ( ) LAB (If available)
Back ( ) ( ) CBC:
Heart ( ) ( ) VIA:
Extremities ( ) ( ) Chest X-Ray:

MENTAL STATUS
(Y) (N)
( ) ( ) Alert, well oriented
( ) ( ) Long and short term memory intact
( ) ( ) Experiencing hallucinations, delusions, or feelings of paranoia
( ) ( ) Calm, cooperati ve

DISPOSITION
(Y) (N) Prescriptions:
( ) ( ) Cleared for basic transfer procedures
( ) ( ) Cleared for litter transfer procedures
( ) ( ) NOT medically cleared for transfer (days/weeks)
Recommended type of confinement ( )Normal ( ) Solitary ( ) Other -explain:
I do not have any SUICIDAL and or HOMICIDAL feelings at this time. If I develop any such ideas or plans, I will notify a

staff member before acting on such feelings or ideas. (SIG.)

Date/Time information transmitted to component surgeon's office
Infection Control recommendations
( ) Standard Precautions
( ) Contact/Droplet Precautions
( ) Airborne Precautions

SCREENER MEDICAL STAFF SIGNATURE
SCREENER MEDICAL STAFF SIGNATURE

DODDOA 026196