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pdfAcuity- Comprehensive Health Services
OMB No. 1652-0032
Exp. 7/31/2023
TRANSPORTATION SECURITY OFFICER
MEDICAL QUESTIONNAIRE
PUBLIC BURDEN and PRIVACY ACT STATEMENTS
PUBLIC BURDEN STATEMENT: TSA is collecting this information to determine suitability to serve as a TSO. This is a voluntary collection of information;
however, failure to furnish the requested information may result in an inability to consider your eligibility for employment as a TSO. TSA estimates that the total
average burden per response associated with this collection is approximately 1.65 hours, including the time for reviewing instructions, getting needed information,
travel time to receive the necessary medical screening, and reviewing the completed form. Send comments regarding our estimate or any other aspect of this form,
including suggestions for reducing burden, to the U.S. Office of Personnel Management (OPM), Strategic Human Resources Policy, Medical Policy and Programs
Division, Attn: OMB Number (1652-0032), 1900 E Street, NW, Washington, D.C. 20415. The OMB number control number assigned to this collection of information
is 1652-0032, which will expire on 7/31/2023. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a valid OMB control number.
PRIVACY ACT STATEMENT: AUTHORITY: 49 U.S.C. 44935 PRINCIPAL PURPOSE(S): This information will be used to determine your eligibility for employment
as a Transportation Security Officer (TSO). ROUTINE USE(S): This information may be shared with contractors, grantees, or volunteers performing or working on a
contract, service, grant, cooperative agreement, or job for the federal government, or for routine uses identified in the Office of Personnel Management’s system of
records notice, OPM/GOVT-10 Employee Medical File System Records (if hired) or OPM/GOVT-5 Recruiting, Examining, and Placement Records (if not hired).
DISCLOSURE: Voluntary; failure to furnish the requested information may result in an inability to consider your application for employment.
INSTRUCTIONS
It is required that you personally complete each question or response in this questionnaire. After completing each page, record
your initials in the space provided at the bottom of each page and print and sign your name on the last page. Your responses
will be reviewed with you by a medical professional.
It is recommended that you review the TSO Medical Guidelines prior to taking the medical assessment. The medical
guidelines can be found at https://jobs.tsa.gov/Resources/TSO_Medical_Guidelines.pdf. Consider bringing medical
records/documentation regarding any chronic diseases or medical conditions, such as recent lab reports or stress
test results to your medical exam appointment. For purposes of this examination, please do not include any genetic
information, including family medical history or the results of any genetic testing, with any medical records/
documentation you provide. NOTE TO MEDICAL EXAMINER: Please do not collect any genetic information provided
by the examinee.
DEMOGRAPHIC INFORMATION
Name (Print):
Last 4 of Social Security #:
XXX - XX -
Address:
Sex: Male
City, State, Zip
Primary Phone #:
(
Secondary Phone #: (
Female
Date of Birth:
)
(mm / dd / yyyy)
)
Height: Feet
Other Phone#:
Inches
Weight
Best Time to Call:
GENERAL INFORMATION
1.
Have you been refused employment, dismissed from a job, or unable to stay in school due to any
medical condition or excessive absenteeism?
1. YES
NO
If YES, please list each medical condition and the year of the refusal/dismissal:
2.
1.
2.
MO/YR
MO/YR
3.
MO/YR
Have you had any operations and/or medical procedures?
2. YES
NO
If YES, describe and indicate date:
3.
1.
2.
MO/YR
MO/YR
3.
MO/YR
Have you had a visit to a clinic, physician, chiropractor, ER, urgent care, outpatient facility,
physical therapist, healer, acupuncturist, or any other practitioner within the past year?
3. YES
If YES, specify condition and healthcare provider consulted, and indicate date:
1.
2.
MO/YR
MO/YR
3.
MO/YR
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OMB No. 1652-0032
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GENERAL INFORMATION (continued)
4.
Are you currently taking any prescription medications?
4. YES
NO
If YES, complete box below. If medication is “as needed” specify approximate frequency. Use back of paper as needed.
NAME OF MEDICATION
5.
REASON FOR MEDICATION
FREQUENCY: HOW
OFTEN DO YOU TAKE
EACH (daily, nightly, etc.)?
DOSE
DATE OF
LAST
DOSE
Are you currently taking any non- prescription OTC medications/herbs/supplements?
5. YES
NO
If YES, complete box below. If medication is “as needed” specify approximate frequency. Use back of paper as needed.
NAME OF MEDICATION
REASON FOR MEDICATION
FREQUENCY: HOW
OFTEN DO YOU TAKE
EACH (daily, nightly, etc.)?
DOSE
DATE OF
LAST
DOSE
EXAMINER COMMENTS – GENERAL INFORMATION:
Examiner MUST enter a comment on all positive history / “yes” answers. Ensure all sections of medication tables are
complete.
VISION and HEARING
6. Do you have known uncorrectable vision loss or a total loss of vision in either eye? … …………………… 6. YES
NO
If YES, indicate date of onset: .……………………………………………………. Date: MO/YR
7.
Have you had any type of refractive eye surgery such as LASIK, PRK, etc.? ……………………………… 7. YES
NO
If YES, answer below:
8.
a.
Type of surgery:
Date: MO/YR
b.
Do you have any dryness that affects your vision?............................. YES
NO
c.
Do you use steroid eye drops? …………………………………………...YES
NO
Do you use a hearing aid for either ear?...................................................................................................... 8. YES
EXAMINER COMMENTS – VISION and HEARING:
Examiner MUST enter a comment on all positive history / “yes” answers.
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OMB No. 1652-0032
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RESPIRATORY
9. Do you have asthma?................................................................................................................................. 9. YES
NO
10. Do you have chronic obstructive pulmonary disease (COPD)?.................................................................... 10. YES
NO
11. Do you have blood in sputum when coughing?............................................................................................. 11. YES
NO
12. Have you EVER had active tuberculosis (not just a positive skin test)? ……………………………………… 12. YES
NO
If YES, answer the questions below:
a.
When was your last Chest X-Ray?........................................................... Date: MO/YR
b.
When were you treated?........................................................................... Date: MO/YR
c.
How long was your treatment?
13. Have you ever had any other lung disease?.................................................................................................13. YES
NO
If YES, specify disease:
EXAMINER COMMENTS – RESPIRATORY:
Examiner MUST enter a comment on all positive history / “yes” answers.
CARDIOVASCULAR
Have you ever had or experienced any of the following?
14. Hypertension? ………………………………………………………………………………………………………… 14. YES
NO
If YES, answer the questions below and Go to APPENDIX A at the end of this document to provide complete information:
a.
Have you had a treadmill exercise stress test? ……………………………YES
NO
If YES, date of most recent? ………………… MO/YR
Was it normal? ………………………………… YES
Don’t know
NO
What METS did you reach? ……..…………….___________________ Don’t know
b.
Have you had any complications of hypertension, such as, stroke, coronary artery disease, left ventricular hypertrophy,
atrial fibrillation, heart failure, nephropathy, retinopathy, or aortic aneurysm? YES
NO
List the complication(s): _____________________________________________________________________________
Complete APPENDIX A at the end of this document.
15. Coronary artery disease, heart attack, open heart surgery, stent, or angioplasty? ………………………... 15. YES
NO
If YES, answer the questions below:
a.
Indicate MO/YR or Not applicable (NA):
Heart attack
b.
Open heart surgery
Stent or angioplasty
Have you had a treadmill exercise stress test with imaging?................... YES
NO
Date of most recent? ………………………… MO/YR
Was it normal? ………………………………… YES
Don’t know
NO
What METS did you reach? ...…………………___________________ Don’t know
c.
Do you have chest pain with exertion or activity? ………………………... YES
d.
Are your risk factors being treated (smoking, hypertension, cholesterol, obesity, etc.)? YES
e.
When was your last heart medication change? ………………………..
f.
Have you been compliant with treatment? ………………………………... YES
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NO
NO
MO/YR
NO
Candidate’s Initials
Acuity- Comprehensive Health Services
OMB No. 1652-0032
Exp. 7/31/2023
CARDIOVASCULAR (continued)
16. Heart failure? ………...................................................................................................................................... 16. YES
NO
If YES, answer the question below:
a.
Have you had an echocardiogram, or stress echocardiogram? ……….. YES
NO
If YES, indicate the ejection fraction if known: …………………………..
% Don’t know
17. Cardiomyopathy? ……………………………………………………………………………………………………… 17. YES
NO
18. Atrial fibrillation, atrial flutter, supraventricular tachycardia, Wolff-Parkinson-White Syndrome or ventricular tachycardia?
……………………………………………………………………………………………………………………………. 18. YES
NO
If YES, answer the questions below:
a.
Did you have an ablation? .………………………………………………… YES
NO
Date(s) of ablation? ………………………………………………………….. MO/YR
b.
Was it successful? …………………………………………………………… YES
NO
Have you had an echocardiogram, or stress echocardiogram? ……….. YES
NO
If YES, indicate the ejection fraction if known: …………………..
c.
% Don’t know
Have you had a treadmill exercise stress test with imaging? …………….YES
NO
Date of most recent? …………………………………………………….. MO/YR
Was it normal? ………………………………………… YES
NO
What METS did you reach? ………………………….. _____
________ Don’t know
Don’t know
19. Ventricular fibrillation? …………………………………………………………………………………………………...19. YES
NO
20. Unexplained syncope (fainting or passing out)? ……………………………………………………………………...20. YES
NO
If YES, date of last occurrence: …………………………………............................
MO/YR _________________
21. Pacemaker? …………………………………………………………………………………………………………..…..21. YES
NO
22. Valvular heart disease? ………………………………………………………………………………………………….22. YES
NO
If YES, specify type:
23. Automatic implantable cardiac defibrillator (AICD)?..………………………………………………………………… 23. YES
NO
24. Peripheral vascular disease that causes pain with walking? ……………………………………………………….. 24. YES
NO
25. Thoracic or abdominal aortic aneurysm? …...………………………………………………………………………….25. YES
NO
26. Other cardiac condition(s) not previously mentioned? ………………………………………………………………..26. YES
NO
Please explain:
EXAMINER COMMENTS – CARDIOVASCULAR:
Examiner MUST enter a comment on all positive history / “yes” answers.
If history of heart failure or cardiomyopathy, what is the NYHA classification, I II III IV:
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Acuity- Comprehensive Health Services
OMB No. 1652-0032
Exp. 7/31/2023
ABDOMINAL ORGANS and RENAL
27. Have you had or do you currently have a hernia? …………………………………………………………………. 27. YES
NO
If YES, answer questions below:
a.
Circle type:
b.
Has it been repaired? ………………………………………………………. YES
inguinal
ventral
umbilical
femoral
NO
c.
Do you have pain, restrictions, or limitations? ………………………….. YES
NO
If YES, specify limitations/restrictions:
28. Do you have chronic kidney disease (CKD)? ……………………………………………………………………… .28. YES
NO
If YES, answer the questions below:
a. What is the stage? (circle response)
1
2
3
4
5
Don’t Know
b. What is your most recent GFR? _____________mL/min MO/YR ___________ Don’t Know ______
29. Are you being treated with hemodialysis or peritoneal dialysis? ….……………………………………………… 29. YES
NO
EXAMINER COMMENTS – ABDOMINAL ORGANS and RENAL:
Examiner MUST enter a comment on all positive history / “yes” answers.
MUSCULOSKELETAL
Have you ever had or experienced any of the following?
30. Amputation or congenitally absent body part?............................................................................................... 30. YES
NO
If YES, answer below:
a.
Specify body part:
b.
Do you use any prosthesis? ……………………………………………. YES
NO
31. Do you use any ambulatory aids (crutches, cane, walker, etc.)? ………………………………………………. 31. YES
NO
If YES, specify:
32. Upper extremity condition (hand, wrist, forearm, elbow, upper arm, shoulder)? ……………………………… 32. YES
NO
If YES, specify:
33. Lower extremity condition (foot, ankle, lower leg, knee, upper leg, hip)? ……………………………………… 33. YES
NO
If YES, specify:
34. Spine condition (back, neck, surgery)? ……………………………………………………………………………. 34. YES
NO
If YES, specify:
35. Joint replacement surgery? ………………………………………………………………………………………… 35. YES
If YES, provide details and dates:
NO
MO/YR
EXAMINER COMMENTS – MUSCULOSKELETAL:
Examiner MUST enter a comment on all positive history / “yes” answers. If examinee has current and temporary physical restrictions
(lift, squat, bend, reach overhead, walk, stand, etc.) document how long the restrictions are expected to last; if not known please state.
SOMQ Candidate Version 4.1
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Acuity- Comprehensive Health Services
OMB No. 1652-0032
Exp. 7/31/2023
NEUROLOGICAL
Have you ever had or experienced any of the following:
36. Cerebrovascular accident (CVA, stroke, brain bleed, or TIA)? ……………………………………….………….36. YES
NO
If YES, answer below:
a.
Specify type and date:
MO/YR
b.
Do you have any residual physical, mental, or emotional impairments or limitations? YES
NO
If YES, explain:
37. Seizures?………………………………………………………………………………………………………………..37. YES
NO
If YES, answer the questions below:
a.
Do you have epilepsy?.............................................................................. YES
b.
What causes your seizures?
c.
Date of last seizure? ……………………………………………………. MO/YR
d.
Date of last evaluation by a neurologist? …………………………….. MO/YR
NO
Don’t Know _________
38. Vertigo? ……………………………………………………………………………………………………………… 38. YES
NO
If YES, specify date of last occurrence: …………………………………... MO/YR
39. Meniere’s disease? ………………………………………………………………………………………………… 39. YES
NO
40. Paralysis of a limb? ………………………………………………………………………………………………… 40. YES
NO
41. Complete loss of touch sensation in upper extremity? …………………………………………………………. 41. YES
NO
42. Cognitive impairment (ongoing memory loss, dementia)? ……………………………………………………... 42. YES
NO
43. Malignancy of the spinal cord or brain? …………………………………………………………………………... 43. YES
NO
44. Amyotrophic lateral sclerosis? ……………………………………………………………………………………... 44. YES
NO
45. Multiple sclerosis? …………………………………………………………………………………………………… 45. YES
NO
If YES, answer questions below:
a.
Specify date of diagnosis: …………………………………………….. MO/YR
b.
Specify date of last relapse: ………………………………………….. MO/YR
c.
Do you have a mood disorder? ……..……………………………….. YES
NO
46. Parkinson’s? …………………………………………………………………………………………………………. 46. YES
NO
47. Other neurologic disorder not previously noted? ………………………………………………………………….. 47. YES
NO
If YES, specify:
EXAMINER COMMENTS –NEUROLOGICAL:
Examiner MUST enter a comment on all positive history / “yes” answers.
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OMB No. 1652-0032
Exp. 7/31/2023
ENDOCRINE
48. Do you have diabetes? …………………………………………………………………………………………….. 48. YES
NO
If YES, answer questions (a) through (o) below and Go to APPENDIX A at the end of this document to provide complete
information:
a.
Are you compliant with your prescribed treatment? ……………………….YES
b.
Have you had an episode(s) of hypoglycemia requiring the help of others in the past three years?
………………………………………………………………………………….. YES
If YES, specify details and dates:
NO
NO
1.
2.
c.
Have you had diabetic ketoacidosis in the past 12 months? ………..… YES
d.
What was your last hemoglobin A1c? …
e.
When was your last hemoglobin A1c? ……………….….……………….. MO/YR
f.
Have you completed diabetes education? ……………………………….. YES
NO
g.
Do you self-monitor your blood glucose? …………………………………. YES
NO
h.
Do you have lightheadedness with standing? …..………….…………… YES
NO
i.
Do you have peripheral neuropathy that interferes with your activity? ... YES
NO
%
NO
Don’t know
If YES, explain:
j.
Do you have chronic kidney disease (CKD)? …………..…………………. YES
If YES, specify GFR
k.
mL/min
NO
Don’t know
Have you had a dilated eye exam? …………..………………………………YES
NO
If YES, specify last exam date:..…………………….……………….. MO/YR
l.
Do you have retinopathy? ……………………….…………………………… YES
NO
m.
Do you have type 1 diabetes treated with insulin?......................................YES
NO
If YES, any change in insulin regimen in the past 6 months? ……… YES
NO
Do you have type 2 diabetes treated with insulin? …...………………….....YES
NO
If YES, any change in insulin regimen in the past 3 months……........YES
NO
Do you have type 2 diabetes treated with non-insulin medication? …...... YES
NO
If YES, any change in medication in the past 30 days? …………...... YES
NO
n.
o.
Complete APPENDIX A at the end of this document.
EXAMINER COMMENTS – Endocrine:
Examiner MUST enter a comment on all positive history / “yes” answers.
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Candidate’s Initials
Acuity- Comprehensive Health Services
OMB No. 1652-0032
Exp. 7/31/2023
SLEEP DISORDERS
Have you ever had or experienced any of the following:
49. Narcolepsy? …………………………………………………………………………………………………….. 49. YES
If YES, is it with cataplexy? …………..…………………………………………………… YES
NO
NO
50. Obstructive sleep apnea? ……………………………………………………………………………………… 50. YES
NO
If YES, answer questions below:
a.
Did you have a sleep study? …………..…………………………………. YES
NO
If YES, What symptoms were you having that prompted the sleep study? (circle all that apply)
Daytime sleepiness
Snoring
Nocturnal awakenings/not breathing
b.
Insomnia
Other
Were you prescribed treatment with CPAP? ……….……………………. YES
If YES, How many days/wk do you wear your CPAP?
NO
How many hrs/night?
(If you have a recent CPAP compliance report, please provide to examiner)
51. Shift work disorder? …………………………………………………………………………………………... 51. YES
NO
52. If YES to narcolepsy, sleep apnea, or shift work disorder, what are your current symptoms from these conditions?
EXAMINER COMMENTS – SLEEP DISORDERS:
Examiner MUST enter a comment on all positive history / “yes” answers.
PSYCHOLOGICAL
Have you ever had or experienced any of the following:
53. Anxiety disorder? ………………………………………………………………………………………………. 53. YES
NO
If YES, date of last occurrence of symptoms? ………………………………………... MO/YR
54. Panic attack? …………………………………………………………………………………………………… 54. YES
NO
If YES, date of last panic attack? ……………..………………………………………… MO/YR
55. Social anxiety disorder? ………………………………………………………………………………………. 55. YES
NO
If YES, date of last occurrence of symptoms? ………………………………………… MO/YR
56. Attention deficit/hyperactivity disorder (ADHD)? ..……………………………………………………….…. 56. YES
NO
If YES, date of last occurrence of symptoms? ………………………………………… MO/YR
57. Bipolar disorder? ……………………………………………………………………………………………….. 57. YES
If YES, did you ever have a manic episode?.............................................................. YES
NO
NO
58. Depressive disorder? ……………………………………………………………………………….…………. 58. YES
NO
If YES, date of last occurrence of symptoms? ……..………………………………….. MO/YR
59. Personality disorder? ………………………………………………………………………………….………. 59. YES
NO
60. Post-traumatic stress disorder (PTSD)? .……………………………………………………………….…… 60. YES
NO
If YES, date of last occurrence of symptoms? …………..…………………………….. MO/YR
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Acuity- Comprehensive Health Services
OMB No. 1652-0032
Exp. 7/31/2023
PSYCHOLOGICAL (continued)
61. Psychosis or psychotic features? ……………………………………………………………………….……. 61. YES
NO
62. Substance use disorder? ………………………………………………………………………………….…… 62. YES
NO
If YES, answer the questions below:
a.
What substance(s)? ____________________________________________________________
b.
Date of last use? …………………………………………………………... MO/YR
c.
Have you completed a substance use disorder treatment program?..…. YES
NO
63. Are you being treated for a mental health condition? ………………………………………………………. 63. YES
NO
If YES, answer the questions below:
a.
Are you treated by a psychologist or psychiatrist? ……………………… YES
NO
If YES, when was your last visit?.............................................................MO/YR
b.
Are you compliant with your treatment
(medications, follow-up appointments, referrals)? ………………………..YES
NO
Date of last treatment ………………………………………………………. MO/YR _____________
c.
Do you have any sedating side effects from your treatment? .…………..YES
NO
d.
Do you have irritability? ….…………………………………………………..YES
NO
e.
Do you have difficulty concentrating? ….…………………………………...YES
NO
f.
Do you have any diagnosed phobias? …….……………………………….YES
NO
g.
Has your condition ever interfered with your job or daily activities?.........YES
NO
If YES, when was the last time your condition interfered with your job or activities? MO/YR
Please explain:
64. Suicide attempt? ………………………………………………………………………………………………... 64. YES
NO
If YES, date: ………………………………………………………………………………….. MO/YR
65. Electroconvulsive therapy? ……………………………………………………………………………………. 65. YES
NO
If YES, date of last ECT therapy: …………………………………………………………... MO/YR
66. Schizophrenia, schizoaffective, or schizophreniform disorder? ………………………………………….… 66. YES
NO
67. Other mental health disorder not previously noted? ………………………………….……………………... 67. YES
NO
If YES, specify:
EXAMINER COMMENTS – PSYCHOLOGICAL:
Examiner MUST enter a comment on all positive history / “yes” answers.
ACTIVITY
68. Answer the questions below regarding your ability. Are you able to:
Frequently lift and carry passenger baggage weighing up to 50 pounds without assistance?...............ABLE
UNABLE
Frequently squat, bend and stoop?....................................................................................................... ABLE
UNABLE
Frequently reach overhead with each arm? ..………………………………………………………………. ABLE
UNABLE
Stand continuously for up to 4 hours without a break? ……………………………………………………..ABLE
UNABLE
Walk for up to 3 miles during a shift? …………………………………………………………………………ABLE
UNABLE
Feel and manipulate small objects with both hands? ……..………………………………………………...ABLE
UNABLE
Open/close zippers, snaps, and buckles on baggage, backpacks, or briefcases? ………………………ABLE
UNABLE
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Acuity- Comprehensive Health Services
OMB No. 1652-0032
Exp. 7/31/2023
ACTIVITY (continued)
What is your present activity level? Circle the level of activity listed below that best describes how often you participate in each of
the activities:
Activit y
Never/ R arel y
Occasi onall y
Frequentl y
0 to 2 times per year
1 to 2 times per month
Once per week or more
Walk 2 miles continuously
Never/Rarely
Occasionall y
Frequentl y
Run 2 miles continuously
Never/Rarely
Occasionall y
Frequentl y
W eight training /general fitness activity at gym
Never/Rarely
Occasionall y
Frequentl y
Team sports (basketball, football, soccer, etc.)
Never/Rarely
Occasionall y
Frequentl y
Gardening / yard work
Never/Rarely
Occasionall y
Frequentl y
Golf
Never/Rarely
Occasionall y
Frequentl y
W inter sports (skiing, ice skating, etc.)
Never/Rarely
Occasionall y
Frequentl y
Swimming / cycling
Never/Rarely
Occasionall y
Frequentl y
Other (list):
Never/Rarely
Occasionall y
Frequentl y
69. Do you have any restrictions or limitations on your activity or function? …………………………………………69. YES
NO
If YES, explain in detail:
70. Do you have anything additional to report that has not already been addressed? ……………………………..70. YES
NO
If YES, explain:
EXAMINER COMMENTS – ADDITIONAL COMMENTS:
Examiner MUST enter a comment on all positive history / “yes” answers.
CANDIDATE SIGNS BELOW after reading the following statements:
I certify that I have reviewed the foregoing information supplied by me and it is true and complete to the best of my knowledge. I have
read the privacy statement at the beginning of this questionnaire and understand that falsification, misrepresentation or omission of information on
Government forms is punishable by fine and/or imprisonment and/or may be grounds for disqualification from TSA employment, or disciplinary or adverse
action if employed.
The exam information collected from your appointment for your TSO pre-placement physical will be forwarded to
TSA’s primary medical contractor, Acuity-Comprehensive Health Services (CHS). Acuity-CHS is the sole authority
for rendering TSO medical qualification determinations and they will contact you directly if they have any questions
or need any further information to make an eligibility determination.
REQUIRED
Candidate Printed Name
Date (mm/dd/yyyy)
REQUIRED
Candidate Signature
FACILITY PROVIDER/EXAMINER (MD, DO, PA, or NP) SIGNS BELOW:
REQUIRED
Examiner Printed Name
Date (mm/dd/yyyy)
REQUIRED
Examiner Signature
SOMQ Candidate Version 4.1
Updated 6/23/2022
MD, DO, PA, NP (circle one)
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Candidate’s Initials
Acuity- Comprehensive Health Services
OMB No. 1652-0032
Exp. 7/31/2023
APPENDIX A
Candidate Name: _____________________________________
If you have a history of Diabetes or Hypertension, complete the following for the purpose of calculating your
ASCVD (atherosclerotic cardiovascular disease) risk score according to the American Heart Association and
American College of Cardiology. This published formula requires the following information to calculate your
ASCVD risk score per the TSO Medical Guidelines: current age, sex, race, systolic blood pressure, total cholesterol,
HDL cholesterol, history of diabetes, smoking, and treatment for hypertension. If you know the following
information, please circle the correct response and enter the values below:
Race (circle one):
White
African American
Other
Total Cholesterol (mg/dL):
_______________ Approximate MO/YR __________ Don’t know ___________
HDL Cholesterol (mg/dL):
_______________ Approximate MO/YR __________ Don’t know ___________
Smoker (circle one):
Yes
Former
No
How long ago did you quit?
______________________
Previous editions of this form are obsolete.
SOMQ Candidate Version 4.1
Updated 6/23/2022
Candidate’s Initials
| File Type | application/pdf |
| Author | lmurphy |
| File Modified | 2022-07-29 |
| File Created | 2020-10-08 |