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Patient:_____________________________________Last 4:_____________
5 Day Blood Pressure Check*
AF Form 781 - Prescription Blank*
Achilles Tendon Injury
Ankle Sprain
Back Pain - Lower
Back Pain - Upper
Birth Control Pill Instructions
Cancer Screening Recommendations
Colorectal Cancer Screening for Women
Common Cold
Depression Tricare Prime
Diabetes Health Tips
Diabetes Self Mgt Health Tips
Diabetes Overview
Diabetes Type 2
Diabetes Home Glucose Monitoring*
Dyspepsia
Elbow (Olecranon) Bursitis
Ganglion Cyst
GERD - Reflux - Esophagitis
Gold Team Primary Care Clinic Information
Golfer’s Elbow – Medial Epicondylitis
Piriformis Syndrome
Plantar Fasciitis
Potassium in Food
Pre-Diabetes – All About
Prothrombin Time (PT) and INR
Pseudofolliculitis Barbae (PFB) Letter
Sacroilitis - Sacroiliac Pain
Safe Medication Practice- How to Take Rx Safely
Seasonal Allergies – Hay Fever
Sexually Transmitted Diseases – Women
Shin Pain – Shin Splints
Shoulder Bursitis
Shoulder – Frozen (Adhesive Capsulitis)
Shoulder – Rotator Cuff Injury
Sleep Tips – Sleep Hygiene
Stroke 101 Fact Sheet
Temporomandibular Joint (TMJ) Pain
Tennis Elbow – Lateral Epicondylitis
Urinary Tract Infections – Women
Warfarin – Oral
Walter Reed Orthotic Lab Request*
Work School Excuse*
Wrist Pain
Wrist Tendonitis
See Reverse Side
24 Hours
48 Hours Comments:_________________________
72 Hours
Condition: ______________________________________
Gout with Dietary Recommendations
Headache – Migraine
Headache – Tension
Headaches – Rebound
Heart Disease Risk Package
Heart Disease – Warning Signs
Homework Pt Handout – Gold Team*
HPV – Fact Sheet
HPV – Common Cervical Questions
HPV Vaccine FAQ
HPV Vaccine Information Statement
Hyperglycemia
Hypoglycemia
Iliotibial Band Syndrome
Ingrown Toenail
Depo Provera Injection – Pt Instruction
Depo Provera – Request for*
IUD
Leave Request (Convalescent)*
Medical Release of Information*
Metered Dose Inhaler – Proper Use
Neck Strain
Nuvaring Pt Instructions
Patellofemoral Pain Syndrome – Runner’s Knee
Pharyngitiis – Sore Throat
Pink Eye
PATIENT HANDOUTS
ORDERS
PROFILE
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
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
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
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

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Provider Tech Handout_23Nov

  • 1. Patient:_____________________________________Last 4:_____________ 5 Day Blood Pressure Check* AF Form 781 - Prescription Blank* Achilles Tendon Injury Ankle Sprain Back Pain - Lower Back Pain - Upper Birth Control Pill Instructions Cancer Screening Recommendations Colorectal Cancer Screening for Women Common Cold Depression Tricare Prime Diabetes Health Tips Diabetes Self Mgt Health Tips Diabetes Overview Diabetes Type 2 Diabetes Home Glucose Monitoring* Dyspepsia Elbow (Olecranon) Bursitis Ganglion Cyst GERD - Reflux - Esophagitis Gold Team Primary Care Clinic Information Golfer’s Elbow – Medial Epicondylitis Piriformis Syndrome Plantar Fasciitis Potassium in Food Pre-Diabetes – All About Prothrombin Time (PT) and INR Pseudofolliculitis Barbae (PFB) Letter Sacroilitis - Sacroiliac Pain Safe Medication Practice- How to Take Rx Safely Seasonal Allergies – Hay Fever Sexually Transmitted Diseases – Women Shin Pain – Shin Splints Shoulder Bursitis Shoulder – Frozen (Adhesive Capsulitis) Shoulder – Rotator Cuff Injury Sleep Tips – Sleep Hygiene Stroke 101 Fact Sheet Temporomandibular Joint (TMJ) Pain Tennis Elbow – Lateral Epicondylitis Urinary Tract Infections – Women Warfarin – Oral Walter Reed Orthotic Lab Request* Work School Excuse* Wrist Pain Wrist Tendonitis
  • 2. See Reverse Side 24 Hours 48 Hours Comments:_________________________ 72 Hours Condition: ______________________________________ Gout with Dietary Recommendations Headache – Migraine Headache – Tension Headaches – Rebound Heart Disease Risk Package Heart Disease – Warning Signs Homework Pt Handout – Gold Team* HPV – Fact Sheet HPV – Common Cervical Questions HPV Vaccine FAQ HPV Vaccine Information Statement Hyperglycemia Hypoglycemia Iliotibial Band Syndrome Ingrown Toenail Depo Provera Injection – Pt Instruction Depo Provera – Request for* IUD Leave Request (Convalescent)* Medical Release of Information* Metered Dose Inhaler – Proper Use Neck Strain Nuvaring Pt Instructions Patellofemoral Pain Syndrome – Runner’s Knee Pharyngitiis – Sore Throat Pink Eye
  • 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