Military

HEALTH ASSESSMENT QUESTIONNAIRES

This appendix contains two recommended health assessment questionnaires that may be used by medical personnel when conducting predeployment and redeployment medical screening. These questionnaires, filled out by the concerned contractor employee, are used along with provided medical records to assess whether or not an individual is medically fit to deploy to an AO and to assess possible long-term health impacts upon their return.

Pre-Deployment Health Assessment Questionnaire

INSTRUCTIONS: Please read each question carefully before marking your selections. Provide a response for each question. If you do not understand a question, ask the medical administrator conducting the medical screening.

Today's date (mm/dd/yy)

Anticipate deployment to

Last name

First name

Middle initial

Social security number
(or other identification number
if not a US citizen)

Date of birth

Gender

Supported military component (select only one)

Citizenship category (select only one)

1.  Would you say your health in general is

2.  During the past 90 days, how often did you seek medical care for an illness?

3.   During the past 90 days, how often did you seek medical care for an injury?

4.   During the past 90 days, how many days of work did you miss due to illness or injury?

5.   During the past year, did you stay in any hospital or medical facility overnight or longer?

6.   Are you currently on light duty or other work restrictions?

7.   Do you currently have any dental problems?

8.   Do you currently have any medical problems?

9.   Do you have any allergies?

10.   Are you regularly taking any medications? (select all that apply)

11.   If you are taking prescription medications or birth control pills, do you have enough to last 90 days?

12.   (For females) What was the result of your last PAP smear? Date of last WWE/PAP_________

13.   (For females) Are you pregnant?

QUESTIONS 14-16 PERTAIN TO YOUR MENTAL HEALTH, WHICH INCLUDES ALCOHOL PROBLEMS, STRESS, DEPRESSION, AND EMOTIONAL PROBLEMS.

14.   During the last 30 days, how many days was your mental health not good?

15.   During the last 30 days, how many days did your mental health keep you from your usual activities, such as self-care, work, or recreation?

16.   During the past year, have you sought counseling or care for your mental health?

17.   During the past 30 days, have you seriously considered injuring yourself or others?

18.   Have you ever suffered or sought treatment for any heat related injury such as heat stroke?

19.   Have you ever suffered or sought treatment for a cold injury such as frost bite or immersion foot?

20.   Do you currently have any questions or concerns about your health?

21.   Do you have concerns about exposure (such as environmental or work-related) that may affect your health?

*Denotes that health care provider must follow-up!

Pre-Deployment Health Provider Review
(for health provider only)
 

Indicate status of each of the following:

[ ]

[ ]

[ ]

I certify that this screening process has been completed.

Medical provider's signature and stamp:

Date:

Redeployment Health Assessment Questionnaire

INSTRUCTIONS: Please read each question carefully before marking your selections. Answer each question. If you do not understand a question, ask the medical administrator conducting the medical screening.

Today's Date (mm/dd/yy)

Anticipate deployment to

Last name

First name

Middle initial

Social security number
(or other identification number
if not a US citizen)

Date of birth

Gender

Supported military component (select only one)

Citizenship category (select only one)

1.  Would you say your health in general is-

2.   Compared to before you were deployed, would you say your health in general is-

3.   During this deployment, how often did you seek medical care for an illness?

4.  During this deployment, how often did you seek medical care for an injury?

5.   During this deployment, how many days of work did you miss due to illness?

6.   During this deployment, how many days of work did you miss due to injury?

7.   During this deployment, did you stay in any hospital or medical facility overnight or longer?

8.  Are you currently on light duty or other work restrictions??

9.  Do you currently have any dental problems?

10.  Do you currently have any medical problems?

11.   Are you regularly taking any medications? (select all that apply)

12.   (For females) Are you pregnant?

QUESTIONS 13-15 PERTAIN TO YOUR MENTAL HEALTH, WHICH INCLUDES ALCOHOL PROBLEMS, STRESS, DEPRESSION AND EMOTIONAL PROBLEMS

13.   During the last 30 days, how many days was your mental health not good?

14. During the last 30 days, how many days did your mental health keep you from your usual activities, such as self-care, work, or recreation?

15.  During this deployment, have you sought counseling or care for your mental health?

16.  During this deployment, have you seriously considered injuring yourself or others?

17.  Do you have concerns about exposure (such as environmental or work-related) during this deployment that you feel may affect your health?

18.  During this deployment, have you suffered or sought treatment for any heat-related injury such as heat exhaustion?

19.   During this deployment, have you suffered or sought treatment for a cold injury such as frost bite or immersion foot?

20.  Do you currently have any questions or concerns about your health?

* Denotes that health care provider must follow-up!

Redeployment Health Provider Review
(for health provider only)

Indicate status of each of the following:

I certify that this screening process has been completed.

Medical provider's signature and stamp:

Date: