Form PHS-7060 Medical History Report

PHS-7060 (3/07)

Page 1

YES

NO

Amphetamines

Barbiturates

Cocaine

Narcotic Drugs

Department of Health and Human Services

Commissioned Corps of the U.S. Public Health Service

REPORT OF MEDICAL HISTORY

(Please read Privacy Act Statement before completing this form.)

OMB No. xxxx-xxxx

OMB approval expires

xx/xx/xx

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 Offi cer, 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: It is intended that this form be completed online. In the event an applicant to the Commissioned Corps of the U.S. Public Health Service cannot complete

this form online, the applicant must complete the form in paper format. ‘Yes’ answers will require the completion of the following questionnaire forms:

Item 13 – PHS-7053, Allergies

Items 50, 51, and 52 – PHS-7055, Injury

Item 16 – PHS-7056, Headache

Item 53 – PHS-7061, Owestry Low Back

Item 19 – PHS-7054, Head Injury

Item 79 – PHS-7057 – GYN

In addition, every ‘Yes’ response in Items 7 through 81 must be explained in Item 83 of this form.

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 fi le 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 se-

lection process and hamper an applicant’s candidacy. Use of the Social Security Number is used

1. NAME (Last, First, Middle Initial)

4. PURPOSE OF EXAMINATION

2. SOCIAL SECURITY NUMBER

3. TELEPHONE NUMBER (Include area code)

5. EXAMINATION FACILITY OR EXAMINER AND ADDRESS (Include ZIP Code)

6. DATE OF EXAMINATION

(MM/DD/YYYY)

PSC Graphics (301) 443-1090

EF

SECTION I

Mark each item “Yes” or “No”. Every question must be answered. Every “Yes” must be explained in the REMARKS section. Mark and explain

each item to the best of your ability. Be perfectly honest! Your medical records may be requested to clarify your medical history.

7. HAVE YOU EVER OR DO

YOU NOW USE ANY OF

THE FOLLOWING:

YES

NO

HAVE YOU EVER HAD OR DO YOU NOW HAVE:

11. Eye trouble (exclude glasses, contact lenses)

12. Have fl uctuating vision or double vision

13. Have any allergies

14. Take any medications regularly

15. Stutter or stammer

16. Frequent, severe, or migraine headaches

17. Fainting or dizzy spells

18. Periods of unconsciousness

19. Head injury or skull fracture

20

Epilepsy, seizures or convulsions

21. Loss of Memory

22. Depression, anxiety, excessive worry, or

nervousness

23. Any mental condition or illness

24. Frequent trouble sleeping

25. Hearing loss

26. Ear, nose, or throat trouble

27. Sinusitis or sinus trouble

28. Hay fever, or allergic rhinitis

29. Tooth / gum trouble, or current orthodontics

30. Thyroid trouble

31. Chronic cough or lung disease

32. Asthma or wheezing

33. Unusual shortness of breath

34. Pain or pressure in chest

35. Palpitation or pounding heart

36. Heart trouble or heart murmur

37. High blood pressure\

38. Coughed up or vomited blood

39. Stomach, liver, or intestinal trouble

YES

NO

Marijuana

Alcohol (Amount, frequency,

treatment, if any)

Chemical inhalants

Hallucinogens

YES

NO

40. Gallbladder trouble or gallstones

41. Hepatitis (yellow jaundice)

42. Hemorrhoids or rectal disease

43. Black or bloody stools

44. Frequent or painful urination

45. Bed wetting after age 12

46. Blood, protein, or sugar in urine

47. History of diabetes

48. Kidney stone

49. Hernia or rupture

50. Any bone or joint problem, injuries, surgery or

medical treatment

51. Steel pins, plates, or staples in any bones

52. Wear a bone or joint brace or support

53. Back pain or trouble

54. Paralysis or weakness

55. Foot trouble / use orthotics

56. Rheumatic fever

57. Tuberculosis or positive TB test

58. Sexually transmitted disease (syphilis, gonorrhea,

herpes)

59. Skin conditions such as acne, psoriasis, hand or

foot rashes, eczema, or dry skin

60. Adverse reaction to vaccines, drugs, medicines,

foods, insect bites or stings

61. Eating disorder

62. Recent gain or loss of weight

63. Excessive bleeding or easy bruising

64. Tumor, growth, cyst, or cancer

65. Considered or attempted suicide

YES

NO

DO YOU

8. Wear glasses

9. Wear contact lenses or

corneal eye retainers

(If Yes, complete 9a.)

10. HAVE YO EVER HAD YOUR VISION IMPROVED BY METHODS OTHER THAN STATED IN

QUESTIONS 8 OR 9?

9a. If you wear contact lenses, how many days have they been

removed prior to this examination?

Less than 3

3 - 20

21 or over

Hard

Soft

T

YPE

OF

LENS

:

YES

NO

66. Sleepwalking episodes after age 12

67. Easily fatigued

68. Motion sickness (car, train, sea, or air)

69. X-ray or other radiation therapy

70. Sensitivity to chemicals, dust, sunlight, etc.

71. Learning disabilities or speech problems

YES

NO

HAVE YOU EVER

72. Been refused employment or been unable to hold

a job or stay in school because of:

a.

Inability to perform certain movements?

b.

Inability to assume certain positions?

c.

Other medical reasons?

73. Been rejected for or discharged from military

service because of physical, mental or other

reasons?

74. Been denied or rated up for life insurance?

75. Received or applied for pension or compensation

for existing disability?

76. Had or been advised to have, any surgical

operations?

77. Consulted, or been treated by clinics, hospitals,

physicians, healers, or other practitioners for

other than minor illnesses?

78. Had any injury or illness other than those already

noted?

YES

NO

FEMALES (Complete Items 79 - 82)

79. Been treated for a female disorder, painful

periods, or cramps

80. Had a change in menstrual pattern

81. Are you now pregnant?

82. Date of last menstrual period (MM/DD/YYYY) :

PROOF

Return completed form to:

OFFICE OF COMMISSIONED CORPS OPERATIONS

ATTN: MEDICAL EVALUATIONS OFFICER

1101 WOOTTON PARKWAY, SUITE 100, PLAZA LEVEL

ROCKVILLE, MD 20852

Mark envelope “TO BE OPENED BY MEDICAL PERSONNEL ONLY”

PHS-7060 (3/07)

Page 2

TYPED OR PRINTED NAME

SIGNATURE

DATE (MM/DD/YYYY)

86. PHYSICIAN OR EXAMINER

87. NUMBER OF

ATTACHED

SHEETS

SECTION II

83. REMARKS. Every “Yes” response in Items 7 through 81 must be explained in the space provided. Give specifi c dates and details including

names of physicians and hospitals or clinics and the current status of the condition. If additional space is needed (for versions of this form without

expandable fi elds) use the “Continued Page” generating feature if available; otherwise, continue on a separate sheet and attach to this form.

84. CERTIFICATION. I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowl-

edge. I authorize any of the physicians, hospitals, or clinics mentioned above to furnish the Government a complete transcript of my medical

record for purposes or processing my application for this employment or service.

TYPED OR PRINTED NAME OF EXAMINEE

SIGNATURE

DATE (MM/DD/YYYY)

NOTE: Mail to Offi ce of Commissioned Corps Operations, Attn: Medical Evaluations Offi cer, 1101 Wootton Parkway, Suite 100, Plaza Level,

Rockville, MD 20852, and mark envelope “To Be Opened By Medical Personnel Only.”

85. EXAMINER’S SUMMARY AND ELABORATION OF ALL PERTINENT DATA. (Examiner shall comment on all “Yes” and blank answers (indicat-

ing the item number before each comment). Develop by interview any additional medical history deemed important, and record signifi cant fi nd-

ings here. If additional space is needed continue on a separate sheet and attach to this form.)

PROOF

ITEMS 85 - 87 MUST NOT BE FILLABLE.

PHYSICIAN / EXAMINER TO FILL THESE ITEMS BY HAND.

(This designer note will be removed on fi nal form.)