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The Medical Examination Form (Armed Forces Retirement Home)

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Country of origin: US
File type: PDF

U.S.A. forms for Armed Forces Retirement Home

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Cover Sheet ME 01-2021
Prior Versions No Longer Valid
ME
MEDICAL
EXAMINATION
Dear Applicant:
The Armed Forces Retirement Home requires the comple-
tion of a comprehensive Medical Examination and current
Tuberculosis Screening for all applicants in order to deter-
mine eligibility for residence.
Please provide this form to a licensed medical provider
[must be a Physician (M.D. or D.O.), Nurse Practitioner (NP)
or Physician’s Assistant (PA)] to complete. In order to be
considered for residency, this form will need to be submit-
ted along with the completed Application Form and Func-
tional Assessment.
Please review the form before submitting and ensure all
items have been completed and that your provider has in-
itialed and signed in all of the appropriate fields. Incom-
plete forms will delay processing of the application.
Thank you
AFRH
RETURN EVALUATION TO:
ARMED FORCES RETIREMENT HOME
PUBLIC AFFAIRS OFFICE #584
3700 NORTH CAPITOL ST, NW
Washington, DC 20011-8400
Fax Number: (202) 541-7519
Telephone: (800) 422-9988 opt. 1
If FAXING documents to AFRH, please make a black
& white copy before sending the fax so that it will be
legible when it is received. Please call and let us
know to look for the documents to come through as
well – thank you for all your help! We want to pre-
vent any delays in processing applications!
Take this form to
Licensed Medical Provider
MD / DO / PA / NP
ARMED FORCES RETIREMENT HOME
Medical Examination
___________________
____
_________
Last Name
MI
Birthdate
ME 01-2021 Page | 0 of 6
Prior Versions No Longer Valid
ME
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C 136, Under Secretary of Personnel and Readiness; 24 U.S.C. 401, Armed
Forces Retirement Home; DoD Directive 5124.09 Assistant Secretary of Defense for Personnel and
Readiness Force Management; DoD Instruction 1000.28, Armed Forces Retirement Home (AFRH);
and E.O. 9397 (SSN), as amended.
PURPOSE: To determine and verify eligibility for admission to the AFRH.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the
Privacy Act of 1974, as amended, the records contained herein may specifically be disclosed out-
side the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: To the Federal Reserve for
processing the debt on the resident account; To authorized contractors or vendors for the purpose
of providing medical services to the residents of the Armed Forces Retirement Home; To any Fed-
eral agency which provides medical services to residents of the Armed Forces Retirement home;
To the Inspector General of the Department of Defense or his/her designee, for conducting inspec-
tions of AFRH records; To a Federal agency, or an organization or person contracting with the AFRH
for information needed in the performance of official duties related to reconciling or reconstruct-
ing data files, compiling descriptive statistics, and/or making analytical or financial studies to sup-
port the function for which the records were collected and maintained; Law Enforcement Routine
Use; Congressional Inquiries Disclosure Routine Use; Disclosure of Information to the National Ar-
chives and Records Administration Routine Use; Disclosure to the Merit Systems Protection Board
Routine Use; and Data Breach Remediation Purposes Routine Use.
The applicable system of records notice is DPR 38 DoD, Armed Forces Retirement Home electronic
Resident Information System (eRIS) and is available at: (ADD LINK WHEN PUBLISHED).
DISCLOSURE: Voluntary; however, failure to provide the required information may result in the de-
lay or denial of admission.
ARMED FORCES RETIREMENT HOME
Medical Examination
___________________
____
_________
Last Name
MI
Birthdate
Page | 1 of 6 ME 01-2021
MD/DO/NP/PA initial EACH page: X Prior Versions No Longer Valid
ME
Patient: Age:
Street: _________________________________________________________________________________ DOB:
City:
State:
Zip:
Phone*: _ Email:
THIS FORM IS TO BE COMPLETED BY THE APPLICANT’S LICENCED MEDICAL PROVIDER
Must be a Physician (M.D. or D.O.), Nurse Practitioner (NP), or Physician’s Assistant (PA) ONLY
This examination form was completed on ________________________ by _________________________________________________
Date Printed Name of physician/nurse performing exam and credentials
Gender
Tobacco-Use
Current Living Situation
Male
Smoker
Lives alone
Single Separated Divorced Widowed
Female
Non-Smoker
Lives with
Spouse Child/Family Other:
Medical History - Please indicate if the person has ANY history of the following conditions
Yes
No
Condition (MARK ALL Y/N)
Yes
No
Condition (MARK ALL Y/N)
Yes
No
Condition (MARK ALL Y/N)
Coronavirus (COVID-19)
Medical Hospitalizations (5yrs)
Vision Loss / Legally Blind / Glaucoma
Anticoagulation Therapy
Psychiatric Hospitalizations
Dementia / Alzheimer’s Disease
Cardiovascular Disease
Facility Treatment for Addiction
Cognitive Impairment / Disorientation
Hypertension / Hypotension
Hospice Care (at home/in facility)
Alcohol Use Disorder / Dependency
Stroke / TIA
Traumatic Brain or Head Injuries
Any Illegal Substance / Drug Use
Heart Attack / MI
Cirrhosis / Liver Failure
Medication Misuse / Dependency
Hemophilia / Blood Disorders
Sleep Apnea / Sleep Disorders
Self-Harm (plans/attempts)
Congestive Heart Failure
Dialysis / Renal Failure
Threatening or Violent Behavior
Edema / Swelling
Allergies / Anaphylaxis
Bipolar or Mood Disorders
COPD / Asthma / Emphysema
Seizures / Epilepsy
Psychosis: ____________________________
High Cholesterol / Taking Statins
Neurological Disorders
Other mental health issue: ________________
Oxygen Therapy
Parkinson’s Disease
Anxiety or Panic Disorders
1=Mild > 4=Severe*
Colostomy / PEG Tube
Immune Disorders
Memory Loss* . . . . .
① ② ③ ④
Diabetes Mellitus
Rheumatoid Arthritis
Chronic Pain*. . . . . .
① ② ③ ④
Amputation: _______________
Gastrointestinal Disorders
Depression*. . . . . .
① ② ③ ④
Cancer: ___________________
Balance Issues / Falls (2yrs)
PTSD*. . . . . . . . .
① ② ③ ④
(Y/N responses are required for every condition above – ANY unmarked items in the history will result in the exam being sent back for corrections):
Describe all POSITIVE responses above and include any history of other conditions not listed above:
When was the patient’s most recent… (approximate dates/timeframes are acceptable, i.e. Fall 2020)
Flu Vaccine: ..
Dental Exam: .
Vision Exam: .
ARMED FORCES RETIREMENT HOME
Medical Examination
___________________
____
_________
Last Name
MI
Birthdate
Page | 2 of 6 ME 01-2021
MD/DO/NP/PA initial EACH page: X Prior Versions No Longer Valid
ME
Medications and Allergies – Please indicate all allergies and current medications for the patient.
List all allergies, including medications, foods, latex, etc.: Patient has no known allergies
1.
4.
2.
5.
3.
6.
List all current medications – attach list as needed
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.
Physician initial here: x
(I confirm that the medications annotated above are accurate and current)
Physical Examination: (completed by provider ONLY (MD, DO, NP, or PA)
Current Vital Signs:
All vital signs must be recorded on the date of the physical examination
ANY blank areas under the physical examination will delay processing.
MUST Include explanation, description, or notes for any indication of abnormalities or health concerns.
Date Vitals Were Taken
Blood Pressure:
Temperature:
Height:
Respiratory Rate:
Pulse:
Weight:
ABN
NOR
Indicate whether or not the following systems are normal - If abnormal, explain:
HEENT:
Head, eyes,
ears, nose,
throat
Cardiovascular:
Lungs:
Thyroid:
Abdomen:
Lymphatic:
Neurological:
Extremities:
Skin:
Neck:
ARMED FORCES RETIREMENT HOME
Medical Examination
___________________
____
_________
Last Name
MI
Birthdate
Page | 3 of 6 ME 01-2021
MD/DO/NP/PA initial EACH page: X Prior Versions No Longer Valid
ME
Tuberculosis Screening Test: Applicant is required to take a Tuberculosis Screening Test for admission to AFRH
TST test: Negative Positive
mm Induration: ___________________mm
Date: ________________________________
If positive, list conversion date:
X-Ray: Negative Positive
If TST is pos.; Chest X-ray results
Date: _______________________________
Findings:
IGRA: Negative Positive
If TST is pos.; Interferon Gold Test
Date: __________________________
Findings:
Signature/Credentials: ___________________________________ Date: ______________
Stamps and/or copies of test results are accepted but the provider MUST mark result & have handwritten signature, credentials, & date in this field.
Covid-19 Screening and Vaccination Information
Has the patient been tested for COVID-19, if so indicate the type of test given (Molecular[PCR], Antigen [AG], Antibody [AB]), results, and date. Has the
patient received a vaccine for COVID-19? If so; identify the vaccine manufacturer and what date/s the doses were administered? Submit a copy of the
CDC vaccination card. If patient has a health concern or other reason for deciding not to be inoculated, indicate reason (allergies, EUA Emergency Use
Authorization, religious objection, not available yet, etc.).
TEST
YES NO
VACCINE
YES NO
REFUSAL REASON N/A
TYPE:
PCR AG AB
MFGR:
PFZ MOD OTH
RESULTS:
NEG POS INC/INV
1
ST
Dose Date:
DATE:
2
ND
Dose Date:
Yes
No
Indicate whether or not following have occurred within the past 12 months:
a. Does the patient have any chronic or acute health issues, disease, physical limitations, or other ongoing concerns?
b. Has the patient had any recent hospitalizations, if so why/when? (If available, please attach discharge notes/info)
c. Has the patient recently had a significant change in sleep patterns, appetite, weight, general physical fitness, or falls?
d. Is the patient currently on hospice, if so please describe medical condition, mental/physical limitations, etc.?
e. Ongoing therapy, treatments, or medications for chronic pain management, insomnia, or mental health conditions.
f. Does the patient currently smoke or vape? If so, is the patient currently on a cessation program and progressing towards quitting their habit?
Smoking is not permitted indoors at AFRH facilities.
Note: During the COVID-19 pandemic, those required to be in quarantine will NOT have any access to outdoor smoking areas.
ARMED FORCES RETIREMENT HOME
Medical Examination
___________________
____
_________
Last Name
MI
Birthdate
Page | 4 of 6 ME 01-2021
MD/DO/NP/PA initial EACH page: X Prior Versions No Longer Valid
ME
INSTRUMENTAL ACTIVITIES OF DAILY LIVING
Is the person able to complete the following tasks INDEPENDENTLY without assistance from another person (patient may use a device such as a
wheelchair, PMD, grab bars, etc. as long as they are able to do so unassisted)?
Yes
No
Yes
No
Independent Mobility / Ambulation
Self-Directed Medication Management
Transferring Positions / Fall Prevention
Self-Directed Feeding / Nutrition Management
Self-Managed Bathing / Showering
Independent Emergency Response / Safety Procedures
Self-Managed Toileting / Continence
Appointment Keeping / Time Management Skills
Personal Grooming / Dressing / Undressing
Self-Managed Light Housekeeping and Laundry
Manages Community Navigation / Transportation
Independent Financial Management, Shopping, etc.
Describe any type of assistance/accommodation needed (including devices, aid from staff, etc.):
Does the patient have any of the following limitations or require any of the supportive items listed below?
Check all applicable items on the list below. If an item on list does not apply, draw a line through the item ( completely cross it out).
Lacks clear communication
(Legally) Blind/low vision
Mobility Devices (walker, PMD)
ESL/limited language skills
Wears corrective lenses
Requires braille/sign language
Non-verbal/mute
Bladder incontinence
Service dog (medical/physical)
Vertigo/seizures/fainting
Urinary catheters
Dentures, partials, or bridge
Oxygen tanks/POC system
PEG tube/CVAD port
Oral health/dental problems
CPAP machine/sleep apnea
Full/partial paralysis
Deaf/low hearing
Wears hearing aid
Bowel incontinence
Colostomy
Amputation/prosthetic
Non-ambulatory
Instability, weakness, fall-risk
Describe type of assistance/accommodation needed:
Note: Individuals requiring language/communication accommodations (i.e.: braille, visual alarms, etc.), service dogs, mobility devices, or other medical equip-
ment may still be considered for an independent living level of care except when staff members must provide regular support to the individual for use/safety.
Cognitive and Behavioral Health Status: ANSWER ALL ITEMS – ANY blank responses will be returned for corrections
Does the patient exhibit any of the following mental health concerns?
Check any applicable items & cross out if not applicable
Memory Loss
Mood / Emotional Instability
Post Traumatic Stress
Suicide Ideation / Attempts
Confusion / Disorientation
Dysthymia / Anhedonia
Irrational Thoughts
Addictive Behaviors
Wandering / Gets Lost
Anxiety / Panic Disorders
Threatening Behaviors
Self-Harm / Risky Behaviors
ARMED FORCES RETIREMENT HOME
Medical Examination
___________________
____
_________
Last Name
MI
Birthdate
Page | 5 of 6 ME 01-2021
MD/DO/NP/PA initial EACH page: X
Prior Versions No Longer Valid
ME
COGNITIVE, BEHAVIORAL, MENTAL HEALTH QUESTIONS - Provide an explanation for any true statements and mark any specific behaviors/items that apply to the patient.
True
False
Indicate if any of the following are TRUE (primary care physician may attach letter or comments to clarify responses)
1.
Demonstrates signs of cognitive decline such as requiring cues/support to perform daily tasks like basic shopping,
managing medications, healthcare decisions, nutrition, or ability to navigate independently -- gets lost, wanders…
2.
Demonstrates decline in the ability to communicate clearly, remember accurately, or make reasonable decisions; and/or
shows poor judgement/risk assessment, poor listening/reading comprehension, or has difficulty in expressing ideas
-- forgetting terms, losing train of thought, repetition of statements …
3.
Demonstrates signs of confusion or lack of orientation (person, place, date/time, or situation); if so, describe…
4. I
f decline in cognition is noted in #1, #2, or #3 above, have you completed a cognitive assessment (i.e.: MoCA, MMSE…)?
Assessment: Score: Date: (attach copy if available)
True
False
Indicate whether these statements are true or false for this individual (within the past 12 months)
Any incidents/behaviors taking place over 12 months ago that have not been resolved or pose any risk should also be disclosed.
5.
Does the patient drink alcohol? How many servings of alcohol does the patient drink on an average week?
☐ #_______
beer (12
oz
/can)
☐ #______
wine (5
oz
glass)
☐ #_______
cocktails/hard-liquor (1.5
oz
/shot)
6.
Drinks 7+ servings of alcohol per week (daily habit) and/or occasionally has 4+ servings at a time (binge)? Describe habits…
7. Do any of the following statements apply to the patient’s use of drugs, alcohol, substances, or other behaviors? If any are true
please indicate the substance/behavior and mark any specific items (underline/circle) that apply to their behavior.
9.
Has the patient EVER been counseled, sought help, or been diagnosed with AUD, SUD, or another addiction? If true, has the
condition been active within the past 12 months? Describe any active use or remissions shorter than 12 months.
☐ YES — active or in early remission ☐NO — in remission longer than 12 months ☐ N/A — no history of this
True
False
Indicate whether these statements are true or false for this individual (occurring within the past 12-24 months)
Any incidents/behaviors taking place over 2 years ago that have not been resolved or pose any risk should be disclosed.
10. Has decreased participation in usual activities, lost interest/quit caring, is bored/listless, lacks enjoyment/motivation; or
has had a significant change in the level of self-isolation, sleep disturbances, personal grooming, or disorganization.
a. Hazardous use - driving intoxicated, falls/injuries, overdosing/black-outs, reckless/illegal activities, risky/erratic behaviors, violence...
b. Use aggravates or causes physical/mental health problems - cirrhosis, COPD, hypertension, cognitive loss, depression, anxiety...
c. Neglects major social/work roles, has developed cravings, or expends a lot of effort/time planning, obtaining, using, recovering...
d. Has had
social/interpersonal
conflicts due to their behavior or has been withdrawing from activities which exclude the substance/behaviors
e. Has failed at attempts to control behavior, has been increasing quantity/time spent, has developed tolerance, or experiences withdrawal
Behaviors/Substances:
Specific issues
:
8.
Has continued to use any alcohol, drugs, tobacco or other substance against medical/professional advice or even when the patient
is aware of adverse drug interactions, specific use-related illnesses, medical complications, cognitive issues, falls/injuries,
psychological/social problems, or otherwise detrimental, dangerous, or hazardous consequences of such use. Explain...
ARMED FORCES RETIREMENT HOME
Medical Examination
___________________
____
_________
Last Name
MI
Birthdate
Page | 6 of 6
ME 01-2021
MD/DO/NP/PA initial EACH page: X
Prior Versions No Longer Valid
ME
11. Reports or exhibits feelings of anxiety, sadness, grief, apathy, depression, moodiness, loneliness, helplessness, hopelessness, or
worthlessness; or shows signs of distress -- crying, irritability, frustration, concentration loss, confusion, anhedonia...
12. Demonstrates signs of behaviors that are antagonistic, menacing, aggressive, combative, hostile, agitated, angry, dangerous,
erratic, volatile, or otherwise intimidating -- fights/yells, makes threats/bullies others, exhibits violent or destructive behaviors...
13. Reports or shows signs of anxiety or post traumatic stress – persistently nervous, withdrawn, detached; has preoccupied/persistent
thoughts or behaviors; avoids certain social interactions/activities; or describes overwhelming feelings of fear, dread, or panic.
14. Exhibits signs of delirium, stupor, idiosyncratic/false perceptions, paranoia, hallucinations, or psychosis. Explain:
True
False
Indicate whether these statements are true or false for this individual (occurring within the past 5 years)
Any incidents/behaviors taking place over 5 years ago that present an ongoing issue or may still pose a risk should be disclosed - mark specific issues
Has been medically advised to seek in-patient or out-patient treatment for a psychiatric condition or addictive behavior.
Has intimidated, threatened, or attempted to harm others and/or may represent a safety risk to the community.
Has expressed a desire, attempted or planned self-harm & may pose a danger to themselves or possible risk of suicide.
Some monitoring, evaluation, or support is necessary for decision making, hazard protection, or psychological health / stability.
Requires intervention from staff members on a regular basis to perform basic activities of daily living.
Requires full-time skilled nursing, rehabilitative, hospice care, or long-term care for current healthcare support.
Patient is mentally and physically capable of living independently in a community environment with elderly residents.
Level of Care: Provider select recommended level of care for this individual: write initials inside the box:
Independent Living
Individual is physically and mentally self-sufficient, stable, and capable of safely managing
activities of daily living without supportive services or aid from others
Home Health Care
Individual is able to manage daily activities independently; however, may require some support
from caregivers, monitoring, supervision, and/or minimal assistance on an intermittent basis
Assisted Care
Includes some assistance from staff with activities of daily living, diversionary activities,
protection from hazards, and/or other supportive services on a regular basis
Skilled Care
Includes professional nursing care and assessment on a daily basis due to a serious condition,
which is unstable, or a rehabilitative, therapeutic regime requiring professional staff
* Stamps are accepted but the provider MUST sign with handwritten signature, license number, and date or the form will be returned.
Please Print (Stamp is acceptable)
Signature, Date and License Number Required
Physician’s Name:
x
Credentials*:
Street Address:
Signature*
City, ST Zip
Phone Number*:
Fax Number*:
Date*
License Number*
*Credentials, phone number and fax number are required to confirm
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Completed 21 June 2021

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