Page 26 - DIDC SOPS and Guidelinesv as of April 2019

Basic Medical Examination Form PMO-6018-01-d

Contingency Released Date
Operations 04/11/18 Page 2 of 4

Name: _____________________________ SS#: __________________________

Are you being treated for any condition now?  Yes No If yes, describe:
________________________________________________________________________________________
________________________________________________________________________________________
Have you ever coughed up blood?  Yes No If yes, describe:
________________________________________________________________________________________

Have you ever noticed blood in your stool?  Yes No In your urine?  Yes No
If Yes, describe: __________________________________________________________________________
________________________________________________________________________________________

Have you ever been hospitalized (hospital, clinic, etc.)?  Yes No Why, Where and When:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Have you ever been absent from work for longer than one month through illness?  Yes No If so, when
and for what illness? ___

________________________________________________________________________________________
Have you ever consulted a neurologist, a psychiatrist or a psychoanalyst?  Yes No If so, please give
his/her name and address
Are you taking any medication regularly?  Yes No If yes, which? _______________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Have you gained or lost weight during the last three years?  Yes No If so, how much?
____
Do you consider yourself to be in good health?  Yes No
Do you smoke regularly?  Yes No If so, what do you smoke?  Cigarettes Pipe  Cigar
Do you drink alcoholic beverages?  Yes No
Has any doctor or dentist advised you to undergo medical or surgical treatment in the foreseeable future?  Yes No
Give any other significant information concerning your health:

List any occupational or other hazards to which you have been exposed:

FEMALES Date of your last Mammogram (age 50+)
Are your periods regular?  Yes No
Date of your last Pap Smear
Are they painful?  Yes No
 Pregnancy Test Results
Date of your last period

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