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pdfNATIONAL SCIENCE FOUNDATION - POLAR PHYSICAL EXAMINATION
MEDICAL HISTORY
Complete pages 1-5 in
Polar Medical Staff Use Only
ink prior to Dr.’s exam
Date: ______________
PQ
PQ Summer Only
NPQ
Medical Condition(s):
Polar Medical Staff Use Only
Restrictions and Follow-up:
______________________________________________________________________________________________
Reviewed by:_________
_____________________________________________________________________________________________
Date: _______________
Reason for NPQ:
____________________________________________________________________________
_
____________________________________________________________________________
Name: last, first, middle (must match passport)
Age:
Birth date (YY/MM/DD):
Sex
F
Nickname (aka)
Maiden Name
M
Previous Name or Other Legal Name:
Street
City
State
Zip
Telephone (include area code):
Day:
Evening:
Mobile:
E-Mail:
Emergency Point of Contact (Name, Address and Phone Number):
Current Deployment Dates:
Job Title:
Previous Polar (Arctic or Antarctic) Deployment?
Dates: __________________
From ______________ to _______________
Location: _________________________
Affiliation:
NSF
Science Event #_______
Technical Event #______
RPSC
Proposed Antarctic Season and Worksite:
Summer (Sep-Feb)
Summer (Mar-Sep)
Winter (Mar-Oct)
Winter (Oct-Feb)
Winfly ________________
(dates)
Summit
VECO
Other:__________________
Proposed Arctic Season and Worksite:
Alaska_____________________________
McMurdo Station
South Pole Station
Palmer Station
RV/NB Palmer
RV/LM Gould
Field Camp ______________
Other:
________________________
USCGC Healy
Field Camp ___________________________________
Other:_______________________________________
NSF Form 1422 Page 1 of 8 (APR 2002)
Original plus one copy to: Contractor Medical Staff
OMB CONTROL NUMBER 3145-0177: Expires SEP 2010
Applicants: Please retain one copy for your records
NAME_______________________________ DOB ______________________
Relationship
Father
FAMILY MEDICAL HISTORY****DO NOT USE FOR YOUR OWN HEALTH HISTORY****
Status of Health and Age, if living
Age and Cause of Death
Mother
Spouse
Brothers/Sisters/Children (list below):
Family History of: Check box, If yes, who?
(Explain.):
Diabetes?
YES
Insulin Required?
Heart Attack?
Relationship
NO
YES
NO
YES
NO
Relationship
Family History of: Check box, If yes, who?
(Explain.):
Kidney Disease? Describe:
YES
NO
Cancer?
YES
NO
YES
NO
YES
NO
Type?
Age? ____________
Stroke?
Age? ____________
YES
NO
Bleeding Disorder?
Describe: (Hemophilia,
Clotting Factor Deficiency)
_____________________
YES
NO
Treatment?
Stomach/GI Disease?
Type?
____________________
____________________
Autoimmune Disorder?
Describe: (Rheumatoid
Arthritis, Lupus, Other)
YES
NO
Mental Health Disorders?
Describe: (i.e.,
Depression, Bipolar,
Suicide, Schizophrenia)
YES
NO
_____________________
______________
Hemoglobin disorder?
Describe: (Sickle Cell,
Thalassemia, etc.)
PERSONAL MEDICAL HISTORY (ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR PRESENT OR PAST MEDICAL HISTORY)
Do you have any allergies to medications?
YES
NO
If yes, which ones?
NSF Form 1422 Page 2 of 8 (APR 2002) Original plus one copy to: Contractor Medical Staff
OMB CONTROL NUMBER 3145-0177: Expires SEP 2010
Applicants: Please retain one copy for your records
NAME_______________________________ DOB ______________________
PERSONAL MEDICAL HISTORY (continued)
Do you have any other known allergies?
YES
NO
If yes, describe (including your reaction).
Medications: List all you take, including Over-the-Counter Medications and Vitamins:
Name of Medication
Dose
How Often Taken – daily, twice daily, as needed, etc.
Surgeries/Hospitalizations – List all surgeries and dates (include any outpatient surgery): If more space is needed, use back or add a sheet.
ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR PRESENT OR PAST MEDICAL HISTORY
1
Neurological Disorder?
a. Multiple Sclerosis
YES
NO
b. Fibromyalgia
YES
NO
c. Other Nerve/Muscle Disorders? (Describe.)
YES
NO
YES
NO
YES
NO
Headaches?
YES
NO
Migraines ?
Date Diagnosed_________________
Date of last Migraine_____________
Do you have diabetes?
Date diagnosed:______________
Insulin
Oral medication
Diet
Controlled by:
Last Emergency Room visit:__________________
Do you have Cholesterol disorders?
Date diagnosed:______________
Diet
Controlled by: Oral medication
Do you have Thyroid Disease?
Explain, if Yes - include medication
YES
NO
YES
NO
YES
NO
YES
NO
ADDITIONAL COMMENTS
____________________________________________
d. Seizure disorder?
Date of Last Seizure:_________________
e. Head Injury?
Loss of Consciousness – Date_______________
How Long_________________
2
3/8
4/9
5/1
2
YES
NO
Surgery required?
When?_____________________
NSF Form 1422 Page 3 of 8 (APR 2002) Original plus one copy to: Contractor Medical Staff
OMB CONTROL NUMBER 3145-0177: Expires SEP 2010
Applicants: Please retain one copy for your records
NAME_______________________________ DOB _______________________
PERSONAL MEDICAL HISTORY (continued)
ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR PRESENT OR PAST MEDICAL HISTORY
6/3
YES
NO
YES
NO
Do you have unequal pupils?
YES
NO
Do you have blindness in one or both eyes?
YES
NO
Do you have Glaucoma?
YES
NO
Do you have Cataracts
YES
NO
Do you have Double Vision?
YES
NO
Do you have other vision problems?
Describe:
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Chronic Obstructive Pulmonary Disease (COPD)?
YES
NO
Pulmonary Embolism/Blood Clots?
YES
NO
Sleep Apnea?
YES
NO
Asthma?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Vision: Do you wear glasses?
contacts?
7/4
Dizziness/Fainting
Reason:
ADDITIONAL COMMENTS
Date of occurrence:_____________________
8/5
Do you have ear, nose, or throat problems?
Describe:
Hearing Impairment?
Hayfever?
Are you currently taking allergy shots?
9/6
Do you have any Pulmonary Disease?
Date of last attack___________________
Number of attacks in past year_________
Hospitalizations?
Nebulizer treatment in the past year?
How often?___________________________
Emphysema or chronic Bronchitis or Bronchiectasis?
Shortness of Breath of Difficult Breathing?
Explain:
Tuberculosis
History of positive TB skin test
Have you ever received BCG?
Have you ever experienced altitude sickness?
At what altitude_______________
Describe treatment:
NSF Form 1422 Page 4 of 8 (APR 2002) Original plus one copy to: Contractor Medical Staff
OMB CONTROL NUMBER 3145-0177: Expires SEP 2010
Applicants: Please retain one copy for your records
NAME_______________________________ DOB _______________________
PERSONAL MEDICAL HISTORY (continued)
ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR PRESENT OR PAST MEDICAL HISTORY
10/
7
YES
NO
Previous Heart Attack?
YES
NO
Angina/Chest Pain?
Describe (include frequency, precipitating factors,
and treatments): __________________________
YES
NO
Congestive Heart Failure (CHF)?
YES
NO
Supraventricular Tachycardia (SVT)?
Date diagnosed_________________
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Hypertension?
Date diagnosed_________________
YES
NO
TIA/Stroke?
Date _________________
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Do you have Heart Problems/Disease?
ADDITIONAL COMMENTS
________________________________________
________________________________________
Frequency and treatment:___________________
________________________________________
Atrial Fibrillation?
Date diagnosed_________________
Heart Murmur/Valvular Heart Disease?
Date diagnosed_________________
Limitations:
Angiogram
Angioplasty
Cardiac Bypass Surgery
Date_________________
Stent
Pacemaker?
History of Deep Vein Thrombosis (DVT)/Blood
Clots?
History of Abdominal or Cerebral Aneurysm?
11/
10
Arthritis?
Type: ___________________
Permanent disability?
12/
11
Do you have Gout?
If so, describe your treatment plan
YES
NO
13
Have you ever used tobacco/tobacco products?
YES
NO
Do you currently use tobacco/tobacco products?
YES
NO
Type of use
cigarettes
cigar
pipe
chew
Packs per week? __________
If you’ve quit, last year of use_______________
Number of years of tobacco use in past ____________
NSF Form 1422 Page 5 of 8 (APR 2002) Original plus one copy to: Contractor Medical Staff
OMB CONTROL NUMBER 3145-0177: Expires SEP 2010
Applicants: Please retain one copy for your records
NAME_______________________________ DOB _______________________
PERSONAL MEDICAL HISTORY (continued)
ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR PRESENT OR PAST MEDICAL HISTORY
14
Have you had an Exercise Stress Test/Treadmill?
YES
NO
ADDITIONAL COMMENTS
If yes, when?____________________________
15
Do you have a regular exercise program?
Describe:
YES
NO
16
Have you had Stomach/Bowel Problems?
Anemia
Black tarry stools
Blood in stools
Frequent or persistent diarrhea
Gallbladder Problems/Stones
Heartburn
Hemorrhoids
Inflammatory bowel disease (Crohns/Ulcerative Colitis)
Ulcers
Date of last flare up_____________________
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
17
Have you been diagnosed with liver problems?
Hepatitis?
B
C
Other________________
Type A
YES
YES
NO
NO
Hepatitis vaccine
YES
NO
YES
YES
YES
YES
NO
NO
NO
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
YES
YES
YES
NO
NO
NO
NO
YES
NO
18
19
Dates: ____________ _______________
(first)
(second)
Do you have Kidney problems?
History of Kidney Stones?
Polycystic Kidney Disease?
Frequent Urinary Tract Infections?
____________
(third)
Do you have a history of Hernias?
Date___________________
Location_____________________________________
20
Have you had any sexually transmitted diseases?
When? _______________________
Type:
Herpes
Syphillis
Chlamydia
Gonorrhea
Other Specify)________________
Treated?
When? ______________________
Describe:
21
Cancer or leukemia?
Type/Location:_______________________________
Date diagnosed______________________________
Surgery
Chemotherapy
Radiation Therapy
Other Treatment:___________________________
22
Skin rash/Disease?
Describe (include duration and treatment):
NSF Form 1422 Page 6 of 8 (APR 2002) Original plus one copy to: Contractor Medical Staff
OMB CONTROL NUMBER 3145-0177: Expires SEP 2010
Applicants: Please retain one copy for your records
NAME_______________________________ DOB ______________________
PERSONAL MEDICAL HISTORY (continued)
ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR PRESENT OR PAST MEDICAL HISTORY
23
24
Broken bones? For any “YES” answers, list date, area
affected and treatment:
YES
NO
Orthopedic Pins/Plates?
YES
NO
Dislocations?
YES
NO
Back injuries?
For any “YES” answers, list date, area affected and
treatment:
YES
NO
Chronic Pain? Describe.
YES
NO
Have you ever been or are you currently treated for?
YES
NO
Have you ever been hospitalized for psychiatric treatment?
Describe with length and dates:
YES
NO
Do you drink alcohol?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Schizophrenia
Anxiety Attacks
Depression
Panic Attacks
Obsessive/Compulsive Disorder
Suicide Attempt/Thoughts
Addiction
Bipolar
ADDITIONAL COMMENTS
Eating Disorders
Other:_________________
Post Traumatic Stress Syndrome?
25
Quantity per day_________ Total per week________
Have you ever felt you should decrease your drinking?
Explain:
Have you ever received a DUI or court ordered treatment?
Describe circumstances:
Have you ever been diagnosed as an alcoholic?
If now sober, length of sobriety_________________
26
For Men:
History of Prostate disease including prostatitis or prostate
stones?
When? Describe treatment:
Surgery required?
Date_______________________
NSF Form 1422 Page 7 of 8 (APR 2002) Original plus one copy to: Contractor Medical Staff
OMB CONTROL NUMBER 3145-0177: Expires SEP 2010
Applicants: Please retain one copy for your records
NAME_______________________________ DOB ______________________
PERSONAL MEDICAL HISTORY (continued)
27 For Women:
Date of last period: _______________________________
Date of last PAP Smear: __________________________
Results:
Normal
Other (describe):
Are you currently taking Oral contraceptives?
YES
NO
History of severe Menstrual Cramps/PMS?
YES
NO
Endometriosis?
YES
NO
Ovarian Cysts?
YES
NO
Describe treatment:
I certify that the information contained herein is complete and accurate to the best of my knowledge. I will inform the
contractor’s medical staff of ALL medical/health changes that occur after submitting this form. I understand that failure to
provide any or all of the requested information may result in a denial of my application for assignment to the Polar Regions.
I also understand that willfully providing false statements to a Federal agency or its representatives is a criminal offense.
_________________________________________________ ___________________________________________ __________________
Print Name
Signature
Date
NSF Form 1422 Page 8 of 8 (APR 2002) Original plus one copy to: Contractor Medical Staff
Applicants: Please retain one copy for your records
OMB CONTROL NUMBER 3145-0177: Expires SEP 2010
| File Type | application/pdf |
| File Title | NATIONAL SCIENCE FOUNDATION |
| Author | Gwendolyn Montez Adams |
| File Modified | 2007-09-24 |
| File Created | 2007-09-21 |