Name: STEVENS,GARRY A III SSN (last 4): 0407

Demographics
Name (First, Last): SSN:
STEVENS,GARRY A III 619320407

Address: City, State, Zip:

210 EASY STREET HINESVILLE, GA 31313

Address 2: Phone Number:

9126100811

Email: UIC:
garry.a.stevens@us.army.mil WH7XAA

Date of Birth: Gender:

12/10/1987 X Male Female

Component: X Active Army Army Reserve Army National Guard Rank:

E4

Allergies
Are you allergic to any of the following
If yes, please state if the reaction is mild, moderate, or severe.
Allergy Reaction Comments Allergy Reaction Comments
X None Adhesive Tape:

Milk: Bee Stings:

Eggs: Shell Fish:

Iodine: Nickel:

Latex: Nuts:

Other:

Medicine Allergies – Are you allergic to any of the following:

If yes, please state if the reaction is mild, moderate, or severe.
Allergy Reaction Comments Allergy Reaction Comments
X None Penicillin:

Sulfa Drugs: Codeine:

Vaccines: Aspirin:

Other:

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 Name: STEVENS,GARRY A III SSN (last 4): 0407
Overall Health – If you answer yes to any question please provide comments.
1. Do you currently have or have you had dental problems since your last military exam?
Yes X No
Soldier Comments:

Provider Comments:

2. Have you been seen or treated by a health care provider since your last military exam?
X Yes No
Soldier Comments:
SEEN FOR BACK INJURY AT TMC.
ENTERED ER FOR WOUND TO LEFT HAND/FOLLOWED UP AT TMC/REFERED TO ORTHOPEDICS/WAITING FOR FOLLOW UP.

Provider Comments:

3. Have you been hospitalized or had surgery since your last military exam?
Yes X No
Soldier Comments:

Provider Comments:

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 Name: STEVENS,GARRY A III SSN (last 4): 0407
4. Are you taking any over the counter medications, prescription medications, and/or supplements?
Yes X No
List Medications:

4a. If yes, are you having any side effects from the medication?
Yes No
5. Are you currently receiving any VA disability, workman’s compensation, or other type of compensation for health or physical reason?
Yes No
Soldier Comments:

Provider Comments:

6. Are you on a profile or do you have a medical condition that keeps you from taking any part of the APFT, requires you to take alternate APFT
event, or keeps you from doing your military job duties?
Yes X No

Provider Comments:

Current Health
Symptom Do you or Currently Soldier Comments Provider Comments
have you treated?
ever had:
Heart Yes X No Yes No
trouble/chest
pain

Heart Yes X No Yes No

murmur

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 Name: STEVENS,GARRY A III SSN (last 4): 0407
Symptom Do you or Currently Soldier Comments Provider Comments
have you treated?
ever had:
High blood Yes X No Yes No
pressure

Rheumatic Yes X No Yes No

fever

Stroke Yes X No Yes No

Frequent X Yes No Yes X No

headaches

Thyroid Yes X No Yes No

disease

Back pain X Yes No X Yes No WENT TO TMC, RECIEVED MEDICINE

Kidney Yes X No Yes No

disease

Liver disease Yes X No Yes No

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 Name: STEVENS,GARRY A III SSN (last 4): 0407
Symptom Do you or Currently Soldier Comments Provider Comments
have you treated?
ever had:
Sinus Yes X No Yes No
disease

Hives/rash Yes X No Yes No

Asthma/hay Yes X No Yes No

fever

Diabetes Yes X No Yes No

Tuberculosis Yes X No Yes No

Joint pain Yes X No Yes No

Chronic pain Yes X No Yes No

Epilepsy Yes X No Yes No

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 Name: STEVENS,GARRY A III SSN (last 4): 0407
Symptom Do you or Currently Soldier Comments Provider Comments
have you treated?
ever had:
Ulcers Yes X No Yes No

Anemia Yes X No Yes No

Cancer Yes X No Yes No

Mental Yes X No Yes No

health
concerns

Other Yes X No Yes No

(please list):

Preventive Health – If yes is checked enter a Referral or check Education.

Referral Options: Military Treatment Facility; Division/Line Based Medical Resource; VHA; Vet Care; TRICARE Provider; Contract
Support; Community Service; Primary Care Manager; Soldier Declined; Civilian Behavioral Health; Military One Source; Other.
Tobacco Use:
Do you smoke any kind of tobacco products? X Yes Referral:
No
Education
If Yes, please answer the following questions:

1. How soon after you wake up do you smoke your first cigarette? 2. Do you find it difficult to refrain from smoking in places
X After 60 minutes where it is forbidden?
31-60 minutes Yes
6-30 minutes X No
Within 5 minutes
3. Which cigarette would you hate most to give up? 4. How many cigarettes per day do you smoke?
The first in the morning X 10 or less
X Any other 11-20
21-30
31 or more
5. Do you smoke more frequently during the first hours after awakening than 6. Do you smoke even if you are so ill that you are in bed most
during the rest of the day? of the day?
Yes Yes
X No X No

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 Name: STEVENS,GARRY A III SSN (last 4): 0407
Do you dip or chew? X Yes Referral:
No
Education
If Yes, please answer the following questions:

1. How soon after you wake up do you place your first dip? 2. How often do you intentionally swallow tobacco juice?
X After 60 minutes Always
31-60 minutes Sometimes
6-30 minutes X Never
Within 5 minutes
3. Which chew would you hate most to give up? 4. How many cans/pouches per week do you use?
The first in the morning More than 3
X Any other 2-3
X1
5. Do you chew more frequently during the first hours after awakening than 6. Do you chew even if you are so ill that you are in bed most
during the rest of the day? of the day?
Yes Yes
X No X No
Alcohol Use:
How often do you have a drink containing alcohol? Referral:
Never
X Monthly or less Education
2-4 times a month
2-3 times a week
4 or more times a week
If you answer anything other than never, please answer the following questions:
How many drinks containing alcohol do you have on a typical day when you How often do you have six or more drinks on one occasion?
are drinking? X Never
1-2 Less than monthly
X 3-4 Monthly
5-6 Weekly
7-9 Daily
10 or more
Do you use alcohol more than you mean to? Have you felt that you wanted to or needed to cut down on your
Yes drinking?
X No Yes
X No

Behavioral Health
Referral Options: Military Treatment Facility; Division/Line Based Medical Resource; VHA; Vet Care; TRICARE Provider; Contract Support;
Community Service; Primary Care Manager; Soldier Declined; Civilian Behavioral Health; Military One Source; Other.
Mental Health
Little interest or pleasure in doing things? Feeling down, depressed, or hopeless?
Yes Yes
X No X No
If you answer yes to either question, please answer the following questions:
Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things?
Not at all Several Days More than half the days Nearly every day
Feeling down, depressed, or hopeless?
Not at all Several Days More than half the days Nearly every day
Trouble falling asleep or staying asleep, or sleeping
Not at all Several Days More than half the days Nearly every day
too much
Feeling tired or having little energy
Not at all Several Days More than half the days Nearly every day
Poor appetite or overeating
Not at all Several Days More than half the days Nearly every day
Feeling bad about yourself – or that you are a failure
Not at all Several Days More than half the days Nearly every day
of that you have let yourself or your family down
Trouble concentrating on things, such as reading the
Not at all Several Days More than half the days Nearly every day
newspaper or watching television
Moving or speaking so slowly that other people
could have noticed. Or the opposite – being so
Not at all Several Days More than half the days Nearly every day
fidgety or restless that you have been moving around
a lot more than normal
Thoughts that you would be better off dead, or of
Not at all Several Days More than half the days Nearly every day
hurting yourself in some way

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 Name: STEVENS,GARRY A III SSN (last 4): 0407
If you checked off any problems, how difficult have
these problems made it for you to do your work, Not difficult at all Somewhat difficult
take care of things at home, or get along with other Very difficult Extremely difficult
people?
Enter a Referral or check education if needed:
Referral:

Education
Additional Comments:

Family History – Choose all that apply for each family member. –Select condition from list for each checked box.
Cancer:
Lung, Breast, Colon,
Prostate, Bone, Brain,
Lymphatic, Skin, Ovarian,
Cervical, Testicular, Renal,
Pancreatic, Esophageal,
Liver, Multiple, Other,
None, Unsure, Unknown
X Father
None
Cardiovascular: Diabetes: Mental Health: Chemical Dependency:
Myocardial infarction, Type 1, Type 2, none, Generalized anxiety disorder, Alcohol, Cocaine/crack,
Cerebral vascular unsure, unknown Depression, Bipolar disease, Heroin, Marijuana,
accident, Coronary Schizophrenia, Obsessive Methamphetamine, Narcotics,
artery disease, compulsive disorder, Glue/solvents, LSD,
hypertension, Cardiac Attention deficit disorder, Benzodiazepines, Ecstasy,
arrhythmia, Congestive Split personality disorder, Multiple, Other, unknown,
heart failure, Personality disorder, unsure, none
Hypercholesterolemia, Adjustment disorder, Eating
Ischemic heart disease, disorder, Tourette syndrome,
Cardiomyopathy, Sudden Agoraphobia, Autism,
cardiac death, Aortic Seasonal affective disorder,
aneurysm, Multiple, Suicide, Multiple, Other,
Other, None, Unsure, unsure, none, unknown
Unknown
X Father X Father X Father X Father
Hypertension None None None

X Mother X Mother X Mother X Mother X Mother

None None None None None

X Sibling X Sibling X Sibling X Sibling X Sibling

None None None None None

Mother’s Side Mother’s Side Mother’s Side Mother’s Side Mother’s Side
X Grandmother X Grandmother X Grandmother X Grandmother X Grandmother
None None None None None

X Grandfather X Grandfather X Grandfather X Grandfather X Grandfather

None Hypertension None None None

Father’s Side Father’s Side Father’s Side Father’s Side Father’s Side
X Grandmother X Grandmother X Grandmother X Grandmother X Grandmother
None None None None None

X Grandfather X Grandfather X Grandfather X Grandfather X Grandfather

None Myocardial Infarction None None None

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 Name: STEVENS,GARRY A III SSN (last 4): 0407
Evaluation – This portion is to be completed by the Provider.
Test Referral Discussion Date of Completion
Cholesterol
Recorded Cholesterol:

Recorded HDL Cholesterol:

Mammogram

Pap Smear
Colorectal Cancer Screening
Three Card Fecal Occult Test
Sigmoidoscopy
Colonoscopy – includes CT colonoscopy
Blood Pressure
Systolic: 115
X 8/26/2009
Diastolic: 66

Visual Acuity Test

20/ .

Chlamydia

Gonorrhea

EKG

Framingham – This portion is to be completed by the Provider.

Blood Pressure: X Untreated Treated Framingham Calculated Risk:
1%

PULHES – This portion is to be completed by the Provider.

PULHES: Height (inches): Weight:
1 P 1 U 1 L 1 H 1 E 1 S
Physical Category Codes: (Enter their priority 1-6 behind each box checked)

A B C D E F G H J L M
N P T U V W MMRB X Y
Deployable to an austere environment within the next 6 months? Pregnant?
Yes No Yes No

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 Name: STEVENS,GARRY A III SSN (last 4): 0407
Additional Comments:

Provider Name: Date:

Provider Signature:
X

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