4. SPECIAL INSTRUCTIONS:
Expiration Date: _________________
Throat Culture Lipid Panel HIV-1 AB Other:
Stept Screen (rapid) Prostate Specific AG Wet Prep
Mononucleosis Screen Thyrotropin zzChlamydia Probe
CBC With Differential Urinalysis Hepatitis Acute PNL
Glucose Fasting Renal Function Rapid Plasma Reagin
ALT/AST Hemoglobin A1C GC/Chlamydia NAAT
Albumin:Creat Ratio PNL Cytologic GYN Radiology
Basic Metabolic Panel GC Culture IV Fluids NS____/cc rate
A=ASAP S=Stat
5. 779th
Profile Template
DUTY LIMITING CONDITIONS
General:
Member non or partial weight-bearing on Lt Rt leg, therefore, no
lifting/carrying/jumping/squatting/kneeling/pushing/pulling or climbing ladders. Authorized
crutches/cane to assist ambulation. Standing/Standing in formation only to tolerance.
No use of Lt Rt arm for lifting/carrying/pushing/pulling more than lbs.
No lifting more than lbs
No carrying more than lbs
No pushing/pulling more than lbs
No jumping
No squatting/crouching/'kneeling
No bending/stooping
No ladders/ropes
No prolonged standing for more than minutes. Allow break of 10 min.
- No prolonged sitting for more than minutes. Allow stretching/standing walking.
Miscellaneous:
No driving GOV due to impairment of extremity
No driving GOV due to medication use
No wear of military boots; nonstandard footgear is authorized
Weapon restriction: All
Weapon restriction: All except handgun
No wear of chem gear gas mask flak vest helmet
No hazardous noise exposure
MOBILITY LIMITING CONDITONS
- Unable to perform heavy physical work over short periods of time. This includes:
- Not able to carry all required deployment baggage (at least 40 lbs)
-Not able to run at least 100yds for safety
Not able to perform duties for a prolonged period (12 hrs or more)
Unable to subsist on field rations for prolonged periods
Not free of medical conditions, including pregnancy or which require:
Special appliances
Follow-up by medical specialists during the period of illness.
Unable to wear or use chem gear [Chemical Warfare Defense Ensemble (CWDE)]
Unable to wear or use gas mask
6. Unable to wear or use flak vest
Unable to wear or use helmet
Does not have sufficient unaided hearing to safely perform duty
Does not have sufficient night vision to travel unassisted at night
Does not have sufficient corrected visual acuity to safely perform duty
Does not have normal tolerance to heat or cold
Has increased predisposition to sudden incapacitation
Cannot travel by either air or sea
FITNESS RECOMMENDATIONS TO FHM/HAWC/PHYSICAL THERAPY
No running for fitness, but can run 100yds for safety/mobility purposes
No cycle
No prolonged walking (more than 1 mile)
No pushups
No sit-ups
No organized calisthenics with upper extremities
No organized calisthenics with lower extremities
Recovering from acute injury/operation. Recommended deferral from testing until___________to allow recovery
7. Unable to wear or use flak vest
Unable to wear or use helmet
Does not have sufficient unaided hearing to safely perform duty
Does not have sufficient night vision to travel unassisted at night
Does not have sufficient corrected visual acuity to safely perform duty
Does not have normal tolerance to heat or cold
Has increased predisposition to sudden incapacitation
Cannot travel by either air or sea
FITNESS RECOMMENDATIONS TO FHM/HAWC/PHYSICAL THERAPY
No running for fitness, but can run 100yds for safety/mobility purposes
No cycle
No prolonged walking (more than 1 mile)
No pushups
No sit-ups
No organized calisthenics with upper extremities
No organized calisthenics with lower extremities
Recovering from acute injury/operation. Recommended deferral from testing until___________to allow recovery