0928c General Medical/Physical Exam Form, National Veterans Su

OMB Number:
Respondent Burden: 20 minutes

GENERAL MEDICAL/PHYSICAL EXAM FORM
NATIONAL VETERANS SUMMER SPORTS CLINIC
(To be completed by Examining Clinician)
PRIVACY ACT: VA is asking you to provide the information on this form under USC, Chapter 5, Section 521 and Chapter 17, Section 1710. VA
may disclose the information that you put on this form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in
the Privacy Act systems of records notices identified as 121VA19 “National Patient Databases - VA”. Providing the requested information is
voluntary. However, you will not be able to participate in the event without furnishing this information.
RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to
respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must
complete this application will average 20 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the
forms.
Dear Clinician: Please fill out completely the two medical pages. In addition, please include (1) a copy of a recent EKG for anyone 40 years of age
and older, (2) a recent H&P/Problem list and (3) a list of current medications and dosages. PLEASE TYPE OR PRINT CLEARLY
SOCIAL SECURITY
DATE
NUMBER (Last 4 digits only)

PATIENT'S NAME

PATIENT'S DAYTIME PHONE
NUMBER (Include area code)

EVENING PHONE NUMBER

AGE

VAMC WHERE PATIENT RECEIVES CARE

PRIMARY DISABILITY/DIAGNOSIS
DATE OF ONSET
SPINAL CORD INJURY (SCI) - LEVEL
PARAPLEGIC

COMPLETE

INCOMPLETE

QUADRIPLEGIC

MULTIPLE SCLEROSIS (MS)
TBI/POLYTRAUMA

LOW

MODERATE

HIGH

CVA WITH RESIDUAL
AMPUTEE

PTSD

LOW

RIGHT LEG, A/K, B/K

RIGHT ARM, A/E, B/E

LEFT LEG, A/K, B/K

LEFT ARM, A/E, B/E

MODERATE

OTHER

HIGH

BURNS
VISUAL IMPAIRMENT DIAGNOSIS (For Visually Impaired patient's ONLY)
IS THE PATIENT LEGALLY BLIND?
NO

YES

VISUAL ACUITY (<20/200 OU)

VISUAL FIELD LOSS (<20 DEGREES OU)

TOTALLY BLIND

DESCRIPTION OF REMAINING VISION?

PLEASE RATE YOUR PATIENTS LEVEL OF INDEPENDENCE
INDEPENDENT WITH SELF CARE NEEDS, INDEPENDENT ONCE ORIENTED
INDEPENDENT WITH SELF CARE NEEDS, NEED SIGHTED GUIDE OCCASIONALLY AFTER ORIENTATION
INDEPENDENT WITH SELF CARE NEEDS, NEED SIGHTED GUIDE CONTINUOUSLY
NEED SOME ASSISTANCE WITH SELF CARE, NEED SIGHTED GUIDE
PATIENT NEEDS
PATIENT REQUIRES ATTENDANT?

YES

NO

USES WHEELCHAIR MAJORITY OF TIME?

YES

NO

WILL THIS PATIENT NEED TO PARTICIPATE
SITTING DOWN?

YES

NO

USES OTHER ADAPTIVE EQUIPMENT?

YES

NO

IF YES, ATTENDANT NAME

IF YES, WHAT

SITTING BALANCE
NORMAL

VA FORM
APR 2010

FAIR

0928c

POOR

Adobe LiveCycle Designer

SOCIAL SECURITY NUMBER
(Last 4 digits only)

PATIENT'S NAME

MEDICAL HISTORY - DO NOT SEND IN WITHOUT ALL OF THE FOLLOWING
1. Attach your H & P (history and physical) problem list with all medical and surgical history.
2. Attach recent EKG for any patient 40 years of age and older.
3. Attach list of current medications.
4. Attach discharge summary for any patient hospitalized during the last three (3) years.
ALLERGIES
DOES THE PATIENT HAVE DYSREFLEXIA?

YES

NO

IF YES, EXPLAIN

DOES THE PATIENT HAVE ANTICOAGULATION
OR OXYGEN REQUIREMENTS?

YES

NO

IF YES, EXPLAIN

DOES THE PATIENT SMOKE?

YES

NO

ALCOHOL OR SUBSTANCE ABUSE?

YES

NO

CARDIOPULMONARY REVIEW OF SYSTEMS
WAS DONE AND IS UNREMARKABLE

YES

IF YES, DESCRIBE

PHYSICAL EXAM (To be filled out completely by physician)
HEIGHT

(inches)

WEIGHT

(pounds)

PULSE

BLOOD PRESSURE

HEENT

CARDIAC

PULMONARY

ABDOMEN

EXTREMITIES

NEURO

Dear Clinician: Your patient is planning on participating in a vigorous outdoor summer sporting rehabilitation clinic. Examples of high-risk patients
are: a smoker who is overweight; brittle diabetics; patients with significant COPD or CHF; and patients that require close medical supervision. High
risk patients: those with potential sun exposure risks and possible hypothermia risks - these events will be outside in high sun and potential cold water
temperatures. Patients are admitted to this clinic based on your judgements about their current health status.
IF THEY REQUIRE HOSPITALIZATION FOR A PRE-EXISTING CONDITION, YOUR MEDICAL CENTER WILL BE LIABLE FOR
ANY CHARGES INCURRED OUTSIDE OF VA CARE. DO NOT SEND ANY PATIENT THAT IS CURRENTLY UNSTABLE OR
UNDERGOING EVALUATION FOR CLINICAL INSTABILITY.
If the patient's condition changes before the event, please contact Dr. John Hunter at the Grand Junction VAMC, (970) 242-0731-page
through operator or contact Department of Medicine, ext. 4247, e-mail [email protected].
PATIENT IS MEDICALLY FIT TO PARTICIPATE

PATIENT IS NOT MEDICALLY FIT TO PARTICIPATE

SIGNATURE AND TITLE OF EXAMING CLINICIAN

NAME OF EXAMING CLINICIAN (Please print)

HOSPITAL AND ADDRESS OF EXAMINING CLINICIAN

TELEPHONE NUMBER

VA FORM 0928c, APR 2010, PAGE 2