Page 28 - DIDC SOPS and Guidelinesv as of April 2019

Basic Medical Examination Form PMO-6018-01-d

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

Name: _____________________________ SS#: __________________________

TO BE COMPLETED BY THE EXAMING PHYSICIAN

Initial: Height:_________ Weight: _________ BMI: ________ Tech Initial:_____________

Repeat: Height:_________ Weight:_________ BMI:________ Tech Initial:_____________

SNELLING CHART GROSS VISION Uncorrected _______ Corrected ________

RIGHT: 20 / _______ LEFT: 20/ __________ BOTH: 20/___________

VACCINES Manufacturer Lot # Exp. Date IM-SQ / L-R

Hep A (1 ml) __________ _________ _________ __________
Hep B (1 ml) __________ _________ _________ __________
MMR(0.5 ml) __________ _________ _________ __________
TDaP(0.5 ml) __________ _________ _________ __________
Typhoid(0.5 ml) __________ _________ _________ __________
Influenza(0.5 ml) __________ _________ _________ __________
Varicella (0.5 ml) __________ _________ _________ __________
Polio (0.5 ml) __________ _________ _________ __________
Yellow Fever (0.5 ml) __________ _________ _________ __________
Meningococcal (0.5 ml) __________ _________ _________ __________
Rabies(0.5 ml) __________ _________ _________ __________
Pneumococcal(0.5 ml) __________ _________ _________ __________
Japanese Encephalitis(0.5 ml) __________ _________ _________ __________

Laboratory (The actual values of each test must be documented)

Blood: Type: Fasting Glucose _________ G6PD
_______
HIV_________ HCG___________

CBC________ Lipid Panel________

 MALARIA PRESCRIPTION  Doxycycline  Mefloquine

If initial BP is greater than 140/90, must have 3 repeats of less than or equal to 140/90

Initial Blood Pressure:_____________ __________ Tech Initial:____________
Systolic / Diastolic / Pulse Date

Repeats 1) ___________ _________ 2)____________ _________ 3)_______________
________
Systolic/Diastolic Date Systolic/Diastolic Date Systolic/Diastolic Date

Name of Examining Physician, Address, and Phone Number Signature

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