Form 1422 Polar Phsyical Examination - Medical History

NATIONAL 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:_________

Reason for NPQ:

Date: _______________

____________________________________________________________________________
____________________________________________________________________________
Name: last, first, middle (must match passport)

Age:

Birth date (MM/DD/YY):

Sex:
F

Nickname (aka)

Maiden Name:

Street

M

Previous Name or Other Legal Name:

City

State

Zip

Telephone (include area code):
Day:

Evening:

Mobile:

E-Mail:

Emergency Point of Contact (Name, Address and Phone Number):

Job Title:

Current Deployment Dates:

Previous Polar (Arctic or Antarctic) Deployment?
Dates: __________________

From ______________ to _______________
Location: _________________________
Affiliation:

NSF

Science Event #_______
Technical Event #______
RPSC
CH2M HILL

Proposed Antarctic Season and Worksite:

Proposed Arctic Season and Worksite:

Summer (Sep-Feb)

Summer (Mar-Sep)

Winter (Mar-Oct)

Winter (Oct-Feb)

Winfly ________________
(dates)

Summit

Alaska_____________________________
McMurdo Station
South Pole Station
USCGC Healy
Other:__________________
Palmer Station
RV/NB Palmer
Field Camp ________________________________
RV/LM Gould
Field Camp ______________
Other:_____________________________________
Other (specify):
______________________________
NSF Form 1422 Page 1 of 5 (JAN 2011) Original plus one copy to: Contractor Medical Staff
Applicants: Please retain one copy for your records
OMB CONTROL NUMBER 3145-0177: Expires

NAME_______________________________
CURRENT MEDICATIONS
Frequency
Name

Name

Dose

Name

TYPE OF REACTION

Condition

Condition

DOB ______________________

ALLERGIES
Name

Dose

Frequency

TYPE OF REACTION

PAST HOSPITALIZATIONS
Date
Condition

Date

PAST SURGERIES
Date
Condition

Date

MEDICAL TESTING/PROCEDURES IN PREVIOUS 3 YEARS
Type (specify body location)
Date
Describe: reason for test procedure and result
MRI
CT
Ultrasound
Angiogram
Biopsy
Other

IMMUNIZATION HISTORY
Date – most recent immunization

Influenza
DT
DPT
Pneumococcus

Dates of immunization
Hepatitis A
Hepatitis B
Other (specify)

NSF Form 1422 Page 2 of 5 (JAN 2011) Original plus one copy to: Contractor Medical Staff
OMB CONTROL NUMBER 3145-0177: Expires

Applicants: Please retain one copy for your records

NAME_______________________________

Tobacco
Do you currently use tobacco products?
Have you used tobacco products in the past?
Alcohol

DOB ______________________

SOCIAL HISTORY
Describe: Packs/week
ye no
s

ye
s

Total yrs.

Year last

no

Do you drink alcohol?
If abstinent, please enter date of your last alcoholic beverage:
Have you ever felt you should decrease your
Describe:
alcohol consumption?
Have you ever received a DUI, DWAI or court
ordered treatment for alcohol?
Have you been diagnosed as an alcoholic?
Exercise and conditioning
yes no Describe:
Do you have a regular exercise program?
Have you had a cardiovascular stress test?
Date of last treadmill:
GENERAL MEDICAL HISTORY
ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR PRESENT OR PAST MEDICAL
HISTORY
Condition
Yes No
Condition
Yes No
2E
Coronary angioplasty/stent/bypass
1
Neurology
1A
Cerebrovascular accident (CVA)
2F
Coronary artery disease
1B
Concussion
2G Heart murmur/valvular heart disease
1C
Dizziness/Loss of Consciousness
2H Hypertension (high blood pressure)
1D
Headaches (Migraine)
2I
Myocardial Infarction (MI)
1E
Headaches (Other)
2J
Supraventricular tachycardia (SVT)
1F
Multiple sclerosis
2K Other cardiac condition
1G
Peripheral neuropathy
3
Vascular disease
1H
Seizures
3A Abdominal aneurysm
1I
Transient ischemic attack (TIA)
3B
Arterial emboli
1J
Traumatic brain injury (TBI)
3C
Cerebral aneurysm
1K
Other neurological disorder
3D Deep venous thrombosis (DVT)
3E
Venous stasis ulcers
2
Cardiology
2A
Angina/chest pain
3F
Other vascular condition
2B
Atrial fibrillation
4
Rheumatologic disease
2C
Cardiac pacemaker/defibrillator
4A Fibromyalgia
2D
Congestive heart failure
4B
Osteoarthritis
For all “yes” answers, please provide details to include age of onset, frequency of event, date of last episode, current
medications, other therapies and status of the condition.

NSF Form 1422 Page 3 of 5 (JAN 2011) Original plus one copy to: Contractor Medical Staff
OMB CONTROL NUMBER 3145-0177: Expires

Applicants: Please retain one copy for your records

NAME_______________________________

DOB ______________________

GENERAL MEDICAL HISTORY
ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR PRESENT OR PAST MEDICAL
HISTORY
Condition
Yes No
Condition
Yes
4
Rheumatologic disease (cont’d)
9
Dermatology
4C
Rheumatoid arthritis
9A
Dermatitis
4D
Systemic Lupus erythematosis
9B
Melanoma
4E
Other rheumatologic condition
9C
Psoriasis/Eczema
9D
Skin cancer
5
Ears Nose and Throat
5A
Hearing impairment
9E
Other skin condition
5B
Nosebleeds
10
Orthopedic
5C
Seasonal Allergies
10A Cervical spine injury
10B Chronic pain
6
Ophthamology
6A
Glaucoma
10C Dislocation
6B
Visual impairment
10D Fractures
6C
Other eye condition
10E
Low back injury
10F
Orthopedic pins/plates
7
Pulmonary
7A
Altitude sickness
10G Other orthopedic condition
7B
Asthma
11
Metabolic
7C
Chronic bronchitis/bronchiectasis
11A Adrenal insufficiency
7D
Chronic obstructive pulmonary disease
11B Diabetes Type I
7E
Dyspnea (shortness of breath)
11C Diabetes Type II
7F
Obstructive sleep apnea
11D Gout
7G
Pulmonary embolism
11E
Hypercholesterolemia
7H
Other pulmonary condition
11F
Hyperthyroidism
11G Hypothyoidism
8
Gastrointestinal disease
8A
Black tarry stools
11H Pituitary insufficiency
8B
Blood in stool
11I
Other hormonal disorder
8C
Cholelithiasis (gallstones)
12
Gynecology-female
8D
Crohn’s disease
12A Menstrual period in past 30 days
8E
Frequent or persistent diarrhea
12B Date of last PAP smear
8F
Gastroesophageal reflux (GERD)
12C Premenstrual syndrome (PMS)
8G
Hemorrhoids
12D Endometriosis
8H
Hepatitis (describe type)
12E
Severe menstrual cramps
8I
Hernia
12F
Ovarian cysts
8J
Irritable bowel syndrome (IBS)
12G Sexually transmitted disease
8K
Pancreatitis
12H Other gynecological conditions
8L
Peptic ulcer disease
8M
Ulcerative colitis
8N
Other gastrointestinal disease
For all “yes” answers, please provide details to include age of onset, frequency of event, date of last episode, current
medications, other therapies and status of the condition.

NSF Form 1422 Page 4 of 5 (JAN 2011) Original plus one copy to: Contractor Medical Staff
OMB CONTROL NUMBER 3145-0177: Expires

No

Applicants: Please retain one copy for your records

NAME_______________________________

DOB ______________________

GENERAL MEDICAL HISTORY
ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR PRESENT OR PAST MEDICAL
HISTORY
Condition
Yes No
Condition
Yes
13
Psychiatric
16
Genitourinary - male
13A
Addiction
16A Prostate disease
13B
Anxiety/panic attacks
16B Sexually transmitted disease
13C
Attention deficit disorder
16C Testicular abnormality
13D
Bipolar
16D Other genitourinary condition
13E
Depression
13F
Eating disorder (bulimia/anorexia)
13G
Hospitalization for psych condition
13H
Post traumatic stress disorder
13I
Schizophrenia
13J
Other psychiatric condition
14
Renal disease
14A
Chronic Renal Disease
14B
Frequent urinary tract infections
14C
Hematuria (blood in urine)
14D
Kidney stones
14E
Other kidney condition
15
Hematology/Oncology
15A
Anemia
15B
Cancer (describe type)
15C
Leukemia
15D
Lymphoma - Hodgkins
15E
Lymphoma – non Hodgkins
15F
Platelet disorder
15G
Other hematologic/oncologic
For all “yes” answers, please provide details to include age of onset, frequency of event, date of last episode, current
medications, other therapies and status of the condition.

No

rtify 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
dical/health changes, including medications, that occur after submitting this form. I understand that failure to provide any or all of the requested informatio
y 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 it
resentatives is a criminal offense.

___________________________________________________
Print Name

______________________________________________
Signature

NSF Form 1422 Page 5 of 5 (JAN 2011) Original plus one copy to: Contractor Medical Staff
OMB CONTROL NUMBER 3145-0177: Expires

___________________
Date

Applicants: Please retain one copy for your records