Form 1423-A Polar Physical Examination

NATIONAL SCIENCE FOUNDATION

POLAR PHYSICAL EXAMINATION
NAME:_________________________________________

DOB:_________________________________

BLOOD TYPE: _______________________
COMPLETE ALL SECTIONS USING CODES WHERE APPROPRIATE
VITAL SIGNS
VISION
WITHOUT CORRECTION

HEIGHT:
BP:
/
RESPIRATIONS:

CODES:

WEIGHT:
HEART RATE:
TEMPERATURE:

DIST
R
L

O – Within Limits
I – Significantly Abnormal
X – Not Examined

1.

General Appearance…...........................

2.

Head and neck…....................................

3.

Eyes…....................................................

4.

Ears…....................................................

5.

Nose…...................................................

6.

Mouth…..................................................

7.

Thyroid…................................................

8.

Lymph nodes…......................................

9.

Chest, Lungs, Breasts…........................

10.

Heart…...................................................

11.

Abdomen…............................................

12.

Inguinal, include hernia….......................

13.

Genitalia…..............................................

14.

Anal and Rectum…................................

15.

Spine…..................................................

WITH CORRECTION

NEAR

DIST

NEAR

R
L

Code

Remarks (discuss abnormal findings in detail)

Forward Bend, Fingers Miss Floor ___ Inches
16.

Upper Extremities…...............................

17.

Lower Extremities…...............................
Varicosities….........................................

18.

Skin, Lymphadenopathy….....................
Identify Body Marks, Scars, Tattoos…....

19.

Peripheral Vascular…............................

20.

Neurologic Status (include Reflexes)….

21.

Emotional Status…................................

22.

Pelvic Exam…........................................

23.

Men > Age 40: Prostate Exam…..........

NSF Form 1423-A Page 1 of 2 (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 ______________________
Physical Examination

Guiac Test
(Required annually for age 50 and up)

Tetanus Immunization Date
(Update every 10 years)

TB Skin Test (Required Annually)

______________
Results

______________________
Date

______________
Results

____________
Date

____________
Date

Examiner’s Diagnoses and Comments:
(Please ask the candidate if there is any other medical information not already obtained which should be known prior to deployment.)

I have thoroughly examined this candidate for travel to the Polar Regions. I have reviewed the participant’s history with him/her, including
ALL positive responses, and commented appropriately. I have performed all diagnostic tests as requested.

_______________________________________________
Examiner’s Name (Type or Print):

_______________________________________
Examiner’s Signature
DATE

_______________________________________________
ADDRESS
_______________________________________________
CITY
STATE
ZIP

I have been informed regarding the medical
examination findings herein (signature optional).

PHONE #:______________________________________
_______________________________________
PATIENT’S SIGNATURE
DATE

Return the completed examination form and results of the requested tests to (return envelope enclosed):
Raytheon Polar Services Company
Attention: MEDICAL
7400 S. Tuscon Way
Centennial, CO 80112-3839
1-800-688-8606 ext 32287 Fax: 303-649-9275
NSF Form 1423-A (Page 2 of 2 (APR 2002)
Original plus one copy to: Contractor Medical Staff
records OMB CONTROL NUMBER 3145-0177: Expires SEP 2010

Applicants: Please retain one copy for your