Part 1: Record of preventative medicine and occupational health
|This is the summary of the care form. It should always be on top and in the front of the records form.
|This is the form that has to deal with Immunization records.
|This is a chronological record of HIV testings
|This form is the prescription glasses and eyewear form.
|This is for a visual record.
|This form is a record of occupational exposure to ionizing radiation.
|This form is used to record the exposure of ionizing radiation from internally deposited radionuclide.
|This is the form for referencing the audiogram.
|This is a form for hearing the conversation data.
|This form is for TB contact converter follow-up.
|This form is used for the asbestos medical surveillance program.
|This form is for asbestos exposure and part of the first part of the initial medical questionnaire.
|Not many changes here, but it’s also the same as above. This form is for asbestos exposure and part of the second part called the periodic medical questionnaire.
|This is the form that covers the medical surveillance questionnaire.
Part 2: Section A
|These are the record identifiers for the Personal Reliability Program (PRP).
|This is the form for medical records that consist of emergency care and treatment record of ambulance care.
|Here we have the HREC which is a chronological record of medical care.
|This is the form for the medical record consultation sheet.
|This is the referral for civilian medical care.
Part 2: Patient deceased records
|This is the form that serves as a declaration or statement of certain information that is true.
|This is the form that’s also known as the certification of death.
|This is the autopsy protocol form.
|This is the form that holds the authorization of autopsy.
|This is the form that handles the disposition of the body.
|This is the form that contains authorization for tissue donation.
Part 2: Section B, Inpatient care, ambulatory surgeries, etc.
|This form serves as the inpatient admission disposition record form.
|This is the basic summary narrative of the visit.
|This is the abbreviated medical record.
|This is the form that has all the progress notes in it.
|This is the form that has the operation reports in it.
|This is the record of medical care that’s in chronological order.
|This is the record for anesthesia operations.
|This is a form that’s a request for the administration of anesthesia.
|This is the record for prenatal and pregnancy civilian medical care notes.
|This is the patient’s evaluation tag.
Part 3: Medical record forms
|This is the medical and dental overseas screening review form for active duty and their dependents.
|This is the form for the report of suitability for overseas assignments.
|This is the medical board report cover sheet.
|This is the medical board statement of the patient form.
|This is the medical board certificate.
|This is the abbreviated temporary limited duty report form.
|This is the form for the physician statement for the employee disability retirement report.
|This is the physical fitness inquiry for motor vehicle operators form.
|This is the certificate of medical examinations form.
|This is the report of medical history.
|This is the report for medical examinations.
|This is the form for the officer physical examination special questionnaire.
|This is the annual certificate physical condition form.
|This is the abstract of service and medical history form.
|This is the injury report form.
|This is the report from the JAG.
|This is an exceptional family member program application.
|This is a third-party collection program.
|This is a living will with the medical power of attorney.
|This is the record of disclosure and it is in compliance with the Privacy Act of 1974.
|This is the form for requesting medical or dental records.
|This is the Privacy Act Statement.
|This is the deoxyribonucleic acid analysis sample pouch.
Part 4: Special forms, inside the back cover
|This is the epilepsy medical report.
|This is the tissue examination report.
|This is the radiographic report.
|This is the radiologic consultation request form.
|This is the medical record-radiographic report.
|This is the blood component transfusion report.
|This is the electrocardiogram request form.
|This is the radiation therapy form.
|This is the radiation therapy summary form.
|This is the interstitial/intercavity therapy form.
|This is the group muscle strength, joint ROM, girth, and length measurements form
|This is the muscle function by nerve distribution which includes the face, neck, and upper extremities.
|This is the muscle function by nerve distribution which includes the trunk and lower extremities.
|This is the neurological examination form.
|This is the anatomical figure form.
|This is the gynecologic cytology from.
|This is the lab report display form.
|These are lab report forms.
|This is the allergen extract prescription for new and refills.
|This is the electroencephalogram request and history form.
|This is the vital signs record form.
|This is the plotting chart form.
|This is the blood pressure plotting chart form.