Occupation Agency Code Work Location Work Supervisor Duty tel. #
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1 PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal or regulatory investigations or prosecutions. The Social Security Number, authorized by Public Law Section 7 (b) and Executive Order 9397, is used as a unique identifier to distinguish between employees with the same names and birth dates and to ensure that each individual's record in the system is complete and accurate and the information is properly attributed. Employee info: Occupation Agency Code Work Location Work Supervisor Duty tel. # Visit for: PERIODIC FORKLIFT OPERATOR / MATERIAL HANDLING EQUIPMENT 710 CERTIFICATION EXAMINATION Medical History 1. Is your work exposure history current (OPNAV 5100/15), and is surveillance/ppe consistent with exposures/occupations 2. Has anything about your health status changed since your last examination 3. Have any medications changed since your last exam 4. Have you ever had a major illness or injury 5. Have you ever had a hospitalization or surgery 6. Have you ever had cancer 7. Have you ever had a back injury 8. Do you drink 6 or more drinks per week (beer, wine, liquor) 9. Have you ever smoked 10. Do you currently smoke or use smokeless tobacco or electronic cigarettes ( packs/day) 11. Heart disease, high blood pressure, stroke or circulation problems 12. Current medication use (prescription or over the counter) 13. Medication allergies 14. Any reproductive health concerns 15. Headache, dizziness, light headedness, weakness 16. Head injury 17. Change or loss of vision in either eye 18. Change or loss in hearing 19. Chest pain, angina, heart attack, irregular heart beat (arrhythmia), palpitation, or other heart problem 20. Repeated episodes of loss of or near loss of consciousness 21. Epilepsy or seizures 22. Problems with balance or coordination 23. Numbness, tingling, or weakness in hands or feet 24. Diabetes (sugar disease) or other endocrine disorder (thyroid, parathyroid, pituitary, adrenal gland) 25. Mental or emotional illness 26. Depression, difficulty concentrating, excessive anxiety 27. Personality or behavior change OF BIRTH (DD-MMM-YYYY) Page 1 of 5 Do not re-use this form after 5/20/2019
2 Medical History (continued) Comments on Medical History: OF BIRTH (DD-MMM-YYYY) Page 2 of 5 Do not re-use this form after 5/20/2019
3 Studies and Immunizations Audiogram (non-hcp) Vision With Correction Without Correction DISTANCE NEAR Right Left Both Right Left Both 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / 20 / Visual fields Horizontal (lateral) field of vision, degrees Right Left Color vision Pass Fail Ishihara - # of plates HRR (Hardy Rand Ritter) City University Farnsworth D15 Other Depth perception Pass Fail Test used: Comments on Studies, Immunizations, and Vision: OF BIRTH (DD-MMM-YYYY) Page 3 of 5 Do not re-use this form after 5/20/2019
4 Vital Signs Blood pressure: Pulse: Respiratory rate: Temperature: Height: Weight: Physical Examination Eyes Ears (tympanic membranes) Cardiovascular system Back & musculoskeletal system Central nervous system Peripheral nervous system (strength, sensation, DTRs) WNL Other (describe) Comments on Physical Exam findings: OF BIRTH (DD-MMM-YYYY) Page 4 of 5 Do not re-use this form after 5/20/2019
5 Assessment Certification Examinations Qualified Not Qualified Pending FORKLIFT OPERATOR / MATERIAL HANDLING EQUIPMENT (710) Disposition and Follow-up Released from Occupational Health Clinic Follow-up with PCM for Return for follow-up exams: FORKLIFT OPERATOR / MATERIAL HANDLING EQUIPMENT. Other disposition: Discussed results of exam with employee Limitations and comments: Provider Signature & Stamp: Date: OF BIRTH (DD-MMM-YYYY) Page 5 of 5 Do not re-use this form after 5/20/2019
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