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Print Form Training Support Detachment WESTPAC HIGH / MODERATE RISK MEDICAL SCREENING FORM TAB B TRAINEE NAME RANK/RATE COMMAND SCREEN DATE COURSE NAME This questionnaire is designed to alert instructors and medical personnel of any condition that may endanger your health or others during high/moderate risk training. This information will be held in confidence the form must be completed prior to participation in high/moderate risk training. Answer each question by placing an X in the Yes or No column* YES NO QUESTION Do you have any fractures sprains splints or casts Do you have a hernia Are you pregnant Do you have pneumonia bronchitis or asthma Have you consumed any alcoholic beverages within the last 12 hours Did you sleep less than 4 hours last night Do you have conjunctivitis eye infection Note Students answering YES to any one of the first seven questions shall be disqualified from participation in high/moderate risk training. If a student answers YES to any of the remaining questions 8-19 an evaluation is required and a decision regarding suitability for participation in high/moderate risk training will be required by appropriate health care providers. Have you had high blood pressure heart disease stress related chest pains or are you currently being treated or monitored for any of these Have you had any surgery or a post-operative procedure within the past 10 days Are you on limited/light duty or have you had a tooth extracted within the past 72 hours Are you NOT within the height/weight or body fat standards established in OPNAVINST 6110. 1 series Are you unable to participate in or complete the PRT Are you taking any medications either prescription or over-the-counter List Medications Do you have hypo tension low blood pressure or hypoglycemia low blood sugar Do you have any open cuts recent stitches or new tattoos within past 72 hours Do you have nasal congestion or an ear/nose/throat infection Do you have a history of heat related illnesses/injuries Have you tested positive for Sickle Cell or G6PD risk training COMMENTS Student SIGNATURE DATE I hereby certify that I have advised the trainee to adhere to a proper diet get adequate sleep and cautioned against the heavy consumption of alcohol for a minimum of 24 hours prior to training commencement. Command Medical Department Representative place an X in the appropriate box for Qualified or Not Qualified then Sign and Date. This information will be held in confidence the form must be completed prior to participation in high/moderate risk training. Answer each question by placing an X in the Yes or No column* YES NO QUESTION Do you have any fractures sprains splints or casts Do you have a hernia Are you pregnant Do you have pneumonia bronchitis or asthma Have you consumed any alcoholic beverages within the last 12 hours Did you sleep less than 4 hours last night Do you have conjunctivitis eye infection Note Students answering YES to any one of the first seven questions shall be disqualified from participation in high/moderate risk training.

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