NOAA Health Services Questionnaire

OMB# 0648-0283
Expires 5/31/2007
Appendix H (rev 7/03)

Page 1

NOAA Health Services Questionnaire
Name
_________________________________________
Last

First

E-Mail: _______________________________
Program ______________________________
Position ______________________________
Scientist
Teacher-at-Sea
Other

Mi.

Birth Date: _________
Sex:
M
F
mm/dd/yy
Work Address _____________________________________ Phone
_________________________________________________

____________________ (W)
____________________ (H)

Cruise dates: ______________________________________ SSN:
______________________________
Citizenship: _______________________________________ Passport No.___________________________
Next of kin: _______________________________________ Next of kin relationship: _________________
Address of next of kin: _____________________________________________________________________
Emergency Contacts (name and phone no.):
#1 ________________________________________
#2 ______________________________________
Medical Insurance Company: _________________________________ Policy No. ___________________
HEALTH INFORMATION
General State of Health:
Excellent
Good
Fair
Poor
Presently under the care of a physician?
No
Yes
Month/Year of most recent Physical Exam? ________ (mm/yy)
Month/Year of most recent Chest X-Ray: ________ (mm/yy) Result ______________________
List current medications (prescription and non-prescription):
1. ____________________________
None
2. ____________________________
3. ____________________________
List Allergies:
None

Allergy

4. ______________________________
5. ______________________________
6. ______________________________
Reaction

1. ______________________
2. ______________________
3. ______________________
4. ______________________

_________________________________________
_________________________________________
_________________________________________
_________________________________________

List ALL active health problems:
1. _________________________________________________________________
None
2. _________________________________________________________________
3. _________________________________________________________________
4. _________________________________________________________________
Major Surgeries / Hospitalizations / Emergency Room visits
Year

None

1. ___________
2. ___________
3. ___________
4. ___________

Reason

_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________

List Any Dietary Restrictions: Restriction
1. ______________________
None
2. ______________________
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Reason

___________________________________________
___________________________________________

NOAA Health Services Questionnaire
Name: __________________________________________
Appendix H

Page 2

GENERAL SCREENING
As an adult, have you had or experienced?
No
Yes
Cancer
Severe Depression

No

Tuberculosis

Paralysis

Asthma

Epilepsy

Hepatitis

Impaired Mobility

Chronic Cough

Severe Hearing Loss

Coughed up Blood

Severe Visual Impairment

Recent unexplained weight gain

Periods of Unconsciousness

or loss of 20 or more lbs.

Yes

Severe Motion Sickness

Female only: Are you pregnant?

Date of last menstrual period ____________

Please explain all YES answers below or on continuation sheet:

CARDIAC SCREENING
As an adult, have you had or experienced?
No

Yes

No

Yes

(and value if known)

Abnormal ECG

Hypertension

recent reading _____

Sedentary Life Style

Diabetes

HgA1C ___________

Family History of Heart

High Cholesterol

recent reading _____

Tobacco Use

packs/day ________

Attack before age 45
Heart Attack

Prolonged Chest Pain

Shortness of Breath

Fainting spells/Syncope

Please explain all YES answers below or on continuation sheet:

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NOAA Health Services Questionnaire

Appendix H

Page 3

Name: __________________________________________
IMMUNIZATION SCREENING
Please list the date(s) you obtained immunizations/prophylaxis against the following diseases:
PPD (TB test) - must be within last 12 months:
Date
1

Date_______

Result_______

Type

Date unknown

None

___________

______

___

Hepatitis A Series: Dose 1

___________

______

___

Dose 2

___________

______

___

Hepatitis B Series: Dose 1

___________

______

___

Dose 2

___________

______

___

Dose 3

___________

______

___

Cholera

___________

______

___

Diphtheria1

___________

______

___

Influenza (most recent)

___________

______

___

Immunoglobulin (IG)

___________

______

___

Malaria

___________ ______________

______

___

Measles, Mumps, Rubella (MMR) ___________

______

___

Polio

___________ ______________

______

___

Typhoid Fever

___________

______

___

Yellow Fever

___________

______

___

Tetanus

Other: Please provide complete information on Continuation Sheet
1

May be given as part of TD vaccination

Are you aware of any other medical condition(s) that may affect your suitability for sea duty?

No

Yes

If yes, please explain on the continuation page
If you have any questions, please contact the appropriate Health Services Office:
Marine Operations Atlantic (757) 441-6320
Marine Operations Pacific (206) 553-8704
Continuation page attached?
No
Yes
The information provided is complete to the best of my knowledge.
________________________________________________________
_________________
Signature
Date (mm/dd/yy)
Forward to the following ships: 1. _________________ 2. _________________ 3. __________________
MEDICALLY CLEARED FOR SEA DUTY BY HISTORY
________________________________________________________
MOA/ MOP Regional Director of Health Services
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YES

NO

NEED MORE INFO

________________
Date (mm/dd/yy)

4 of ___
4
Page ___

NOAA Health Services Questionnaire Continuation Page

Name: __________________________________________

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