DOD Medical Form re: Chronological Record of Medical Care

1,4 7:
HEALTH RECORD
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) . 1.

1.
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 (.)
HIV/TUBERCULOSIS QU ESTIONAIRE Do you have a history or, or do you presently have any of the following symptoms or conditions:
(Y).(N). (Y).(N) (.).(.).Persistent cough/shortness of breath .(.).(.).Cough with blood and/or dry cough (.).(.).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 RECORDS
imprint) MAINTAINED
AT:
PATIENT'S NAME (Last, First, Middle Initial) SEX

RELATIONSHIP TO STATUS RANK/GRADE
SPONSOR DETAINEE
SPONSOR'S NAME ORGANIZATION
DEPART/SERVICE SSN/IDENTIFICATION NO. DOB

780

q3Li DOD-045990
DATE SYMPTOMS, DIAGNOSIS, TREATING 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. (.).(.). U/A:
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, cooperative
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
DOD-045991