Form PHS-7059 Medical Examination Report

Department of Health and Human Services
Commissioned Corps of the U.S. Public Health Service

OMB No. xxxx-xxxx
OMB approval expires
xx/xx/xx

REPORT OF MEDICAL EXAMINATION
(Please read Privacy Act Statement before completing this form.)

The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the HHS / OS Reports Clearance Officer, 200 Independence Avenue, SW, Room 537-H, Washington, DC 20012 (PRA 0990-XXXX). Respondents should be aware
that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
IMPORTANT INSTRUCTIONS: An applicant to the Commissioned Corps of the U.S. Public Health Service (Corps) must NOT have a medical examiner / physician complete this form until
AFTER the applicant receives a personnel order calling the applicant to duty with the Corps.

RETURN COMPLETED FORM TO:
OFFICE OF COMMISSIONED CORPS OPERATIONS, ATTN: MEDICAL EVALUATIONS OFFICER, 1101 WOOTTON PARKWAY, SUITE 100, PLAZA LEVEL,
ROCKVILLE, MD 20852, AND MARK ENVELOPE “TO BE OPENED BY MEDICAL PERSONNEL ONLY.”

OCCO USE ONLY

AUTHORITY: 42 U.S.C. 202 et seq. and Executive Order 9397.
RECORDS SYSTEM: 09-40-0002, “PHS Commissioned Corps Medical Records,” HHS/PSC/HRS.
PRINCIPAL PURPOSE: To determine medical acceptability or update a medical file as part of the application process to the Commissioned
Corps of the U.S. Public Health Service.
ROUTINE USES: None.
DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection process and hamper an applicant’s
candidacy. Use of the Social Security Number is used for positive identification of records.

APPLICANT DATA
1. DATE OF EXAMINATION (MM/DD/YYYY)

2. NAME (Last, First, Middle Initial)

4. DATE OF BIRTH (MM/DD/YYYY)

5. AGE

3. SOCIAL SECURITY NUMBER

6. SEX

7. RACE (Ethnic Group)

8. ADDRESS INFORMATION (If left blank will delay processing)

9. STATUS (X one)

a. Applicant Mailing Address (Include ZIP Code)

Active Duty

Civilian

Reserve / Guard

10. EXAMINER ADDRESS (Street, City, State and ZIP Code)

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b. ROTC Detachment Code (If applicable) :

MEASUREMENTS
11. HEIGHT (to nearest
1/4 inch)
Standing

Sitting

12. BLOOD PRESSURE
Systolic

13. AUDIOMETER
500

Diastolic

1000

2000

3000

4000

6000

16. WEIGHT (to
nearest pound)

Exo ∆

RH ∆

2000

3000

4000

6000

14. READING ALOUD
TEST

Left

Unsatisfactory
(Explain in Item 57)

17. DISTANT VISION

18. REFRACTION

Right

20 /

Corr to 20 /

SPH

Cyl

Axis

20 /

Corr to 20 /

By

Right

20 /

Corr to 20 /

SPH

Cyl

Axis

20 /

Corr to 20 /

By

20. HETEROPHORIA / TROPIA
(Far only)
Eso ∆

1000

Satisfactory
Right

15. PULSE

500

Cyclo

By Lens

22. COLOR VISION

21. COVER TEST

LH ∆

Manifest

Test Used
Pass
(Non-Tropia)

19. NEAR VISION

23. DEPTH PERCEPTION
Results

Test Used

No. Passed:

No. Failed:

VTA-ND / OVT / AFVT

FALANT

No. Passed:

No. Failed:

DPA-V

Other (Specify)

Fail
(Tropia)
24. NEAR POINT OF CONVERGENCE

Score

PIP

Titmus / Stereo Fly
(Arcs per second)
26. OCULAR MOTILITY AND BINOCULARITY (RED LENS TEST)

25. VIVID RED / GREEN (If fail Item 22)
Pass

Fail

Pass

Fail

If Failed:

Diplopia

Suppression

LABORATORY
27. URINALYSIS
Protein

Neg

T

1+

2+

3+

4+

Sugar

Neg

T

1+

2+

3+

4+

Blood

Neg

T

1+

2+

3+

4+

Leukocyte
Esterase

Neg

T

1+

2+

3+

4+

Microscopic Examination (If required) (X one)
Negative
Positive (List results)

28. OTHER REQUIRED TESTS (Specify type and results)
Type
• CBC and Blood Type / Rh Factor
• Hepatitis Profile (over 35 years)
• Metabolic Panel (electrolytes, liver
profile, lipids)
• PAP Smear

PHS-7059 (3/07)

Result

Type

Result

• Mammogram (40 years and over)
• ECG (35 years and over)
• PPD
• HIV
• PSA (40 years and over)

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PSC Graphics (301) 443-1090

EF

CLINICAL EVALUATION
(X each item in the appropriate column.
Enter “NE” if not evaluated)

Normal

Abnormal

(X each item in the appropriate column.
Enter “NE” if not evaluated)

Normal

29. HEAD, FACE, NECK AND SCALP

43. ABDOMEN AN VISCERA (Include hernia)

30. NOSE

44. ENDOCRINE SYSTEM

31. SINUSES

45. SPINE, OTHER MUSCULOSKELETAL

32. MOUTH AND THROAT

46. UPPER EXTREMITIES (Strength, sensation, range of motion)

33. EARS – GENERAL (Internal and external canals)
(Auditory acuity under item 13)

47. LOWER EXTREMITIES (Except feet) (Strength, sensation, range
of motion)

34. DRUMS (Perforation)

48. FEET

35. VALSALVA

49. IDENTIFYING BODY MARKS, SCARS, TATTOOS

36. EYES – GENERAL (Visual acuity and refraction under items 17,
18, and 19)

50. SKIN, LYMPHATICS
51. GU SYSTEM

37. PUPILS (Equality and reaction)
38. OCULAR MOTILITY (Associated parallel movements, nystagmus)

52. ANUS AND RECTUM (Hemorrhoids, fistulae) (Prostrate if
indicated) EXTERNAL EXAM

39. OPHTHALMOSCOPIC

53. FEMALE GU EXTERNAL VISUAL EXAM

40. LUNGS AND CHEST (Include breasts)

54. NEUROLOGIC

41. HEART (Thrust, size, rhythm, and sounds)

55. PSYCHIATRIC (Specify any personality deviation)

42. VASCULAR SYSTEM (Varicosities, etc.)
56. REPEAT BP OR PULSE EXAM (SITTING) IF BP ≥ 140 / 90 OR PULSE ≥ 100

57. NOTES (Describe every abnormality in detail. Enter the item number before each comment.)

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58. EXAMINER (If performed by PA, PCNP, or FNP)
TYPED OR PRINTED NAME

RANK

CORPS OR DEGREE

SIGNATURE

RANK

DEGREE

SIGNATURE

59. PHYSICIAN (MD / DO)
TYPED OR PRINTED NAME

PHS-7059 (3/07)

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Abnormal