The 114 Oklahoma form is a comprehensive document utilized by the Oklahoma Police Pension and Retirement System for physical-medical examination requirements of its applicants. It covers a detailed medical and surgical history, complete physical examination including visual and audiometric testing, alongside laboratory assessments such as blood work, urinalysis, x-rays, and more. Those seeking to complete this thorough health screening process can proceed by clicking the button below.
The 114 Oklahoma form is a comprehensive document employed by the Oklahoma Police Pension and Retirement System to ensure that all applicants for the police service undergo an extensive physical and medical examination. This document is critical in capturing a complete medical and surgical history, encompassing a wide array of tests such as visual and audiometric testing, comprehensive metabolic profiles, cholesterol levels, and screenings for conditions like hepatitis and HIV. It also includes specialized exams depending on past medical history, such as chest and lumbar spine X-rays for those with pertinent issues, and detailed examinations of other potential health concerns from heart conditions to mental health issues. Moreover, the form takes an exhaustive approach by requiring drug screening in adherence to NIDA Standards and delving into family medical history to provide a holistic view of the applicant's health. This meticulous process ensures that each candidate is physically and medically fit to undertake the demanding responsibilities of law enforcement, safeguarding both the officers and the communities they serve. Through this form, the Oklahoma Police Pension and Retirement System sets a high standard for health and fitness, reflecting the importance of wellbeing in law enforcement roles.
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OKLAHOMA POLICE PENSION AND RETIREMENT SYSTEM
PHYSICAL-MEDICAL EXAMINATION
INSTRUCTION TO THE PHYSICIAN
The following History and Physical with Lab Data are required by each applicant:
1.Complete medical and surgical history with dates.
2.Complete physical exam.
3.Visual testing: With and without correction.
Binocular Vision Color Vision
4.Audiometric testing with decibel level.
5.Blood work: A. Comprehensive Metabolic Profile
B.Cholesterol
C.GGTP
D.Complete Blood Count
E.RPR
F.Hepatitis B Surface Antigen – HBSAG
G.Hepatitis B Core Antibody – HBCAB
H.Hepatitis C Antibody – HCV
I.Human Immunodeficiency Virus - HIV
6.Urinalysis with microscopic.
7.X-rays - Chest (PA), lumbar spine (obtain only if history of back problems or surgery).
8.T.B. Skin Test.
9.Pulmonary Function Test.
10.Exercise Tolerance Test (Bruce Protocol) with interpretation.
11.Complete knee examination form if history of knee surgery or significant injury.
12.Urine drug test must meet NIDA Standards.
SSN
NAME
DATE
SEX
RACE
AGE
DATE OF BIRTH
ADDRESS
PHONE (
)
CITY,STATE,ZIP
PHYSICIAN
A.
Have you ever:
YES
NO
1.Received compensation for injury?
2.Received a disability pension?
3.Received medical discharge from armed forces?
4.Been rejected for military service for medical reasons?
5.Been hospitalized?
6.Been operated on?
7.Been rejected in any medical examination?
8.Had allergic reactions to drugs, medications, blood transfusions, insect bites? B. Have you ever had disease or injury to: (Circle affirmative items)
1.Head, ears, eyes, nose, throat?
2.Neck, back, hips, arms, legs, hands, feet?
3.Joints: shoulder, elbows, knees, wrist, ankles?
Form 114 4/08
Page 2
4.Heart: chest pain, palpitations, fainting, shortness of breath with exertion, sudden shortness of breath at night, feet swell, high blood pressure? History of Rheumatic fever or heart murmur, varicosities, deep leg pain (thrombophlebitis), heart attack, or stroke?
5.Lungs: Unusual shortness of breath, sputum production, coughed up blood, chest pain, wheezing, recurrent infections, history of asthma, history of smoking cigarette_____, pipe______, cigar______, other? How many per day?_____ For how many years?______
6.Breast: Pain, masses, nipple discharge? History of trauma, self breast exam and/or history of mammograms?
7.GI: Weight change, nausea or vomiting, vomiting blood, heart burn, abdominal pain, diarrhea or constipation of chronic or unusual character? History of ulcers, rectal bleeding, jaundice, laxative use/abuse?
8.GU: Pain when you urinate, blood colored urine, frequency or urgency to urinate? History of kidney stones, recurrent urinary tract infections, venereal diseases (syphilis, gonorrhea)?
9.Genital Tract:
Female: Age of Menses ______; # of days between periods ______; Date of last regular period ______;
History of severe pain during menstruation? Any history of unusual bleeding between periods? History of vaginal discharge? # of pregnancies ______; # of abortions or miscarriages ______; #
of deliveries ______; Types of contraceptive currently used ______________; date and result of last
pap smear?________________.
Male: Penile pain, discharge or skin lesions? Testicular pain or masses. History of prostate problems, hernias? History of vasectomy?
10.History of anemia, swollen and/or sore lymphnodes, easy or spontaneous bruising, excessive bleeding? History of any type of cancer?
11.History of retarded growth or development? Temperature intolerance, goiter, increased thirst, appetite, or frequency to urinate? History of diabetes, gout, recurrent skin rashes, unusual loss of hair?
12.History of tremor, paralysis, imbalance, muscle weakness or low sensitivity with the sense of touch? History of seizure disorder?
13.History of nervousness, anxiety, irritability? History of depression or suicide? History of psychiatric/psychological evaluation and/or treatment? History of drug or alcohol abuse?
14.History of Hepatitis B, Hepatitis C, HIV or AIDS?
C.Family medical history and any descriptive comments on positively answered question(s) should be completed below.
D.All affirmative answered responses to the health screen if significant or pertinent to current health status of the applicant should be identified and outlined as to the time of onset, duration, location, aggravating or alleviating symptoms and any associated symptoms that are characteristic of the problem.
I certify that the above health information is complete and true to the best of my knowledge. I authorize the medical examiner for the participating municipality to investigate any and all statements of health made herein.
Signature of Examinee
Date
Comments:
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PHYSICAL EXAM AND LABORATORY ASSESSMENT FORM
Name:
City:
Date:
Height:
Weight:
Pulse:
Blood Pressure:
NormalComments
1)Integument
2)Heent
3)Breast
4)Chest
5)Heart
6)Abdomen
7)Genitalia
8)Rectal
9)Stool Guaiac Results
10)Musculoskeletal
11)Neurologic
Laboratory Results
1)
Visual Acuity:
Uncorrected
R______/ L______
Binocular Vision
Corrected
Color Vision
2)Audiometric: (500) ___/___ (1000) ___/___ (2000) ___/___ (3000) ___/___ (4000) ___/___ (6000) ___/___
3)
X-ray A) PA Chest:
B)Lumbar Spine Series
(Obtain only if history of back problem)
4)Please submit copy of:
A. Comprehensive Metabolic Profile
G. Hepatitis B Core Antibody - HBCAB
B. Cholesterol
H. Hepatitis C Antibody – HCV
C. GGTP
I. Human Immunodeficiency Virus – HIV
D. Complete Blood Count
J. Urinalysis
E. RPR
K. Drug Screen
F. Hepatitis B Surface Antigen HBSAG
5)PPD Positive ( ) Negative ( )
Examiner’s Signature
Page 4
SPIROMETRY REPORT
PHYSICIAN:
TEST #:
NAME:
DATE:
AGE:
HEIGHT:
(cm) WEIGHT:
(lbs)
RACE:
SEX:
DIAGNOSIS:
ASTHMA
TUBERCULOSIS
HISTORY:
BRONCHITIS
HYPERTENSION
MORNING COUGH
EMPHYSEMA
CHEST PAIN
SPUTUM COLOR
LUNG CANCER
OTHER
SPUTUM AMOUNT
SMOKING:
MEDICATION NOW TAKING:
A.Never used
B.
Used to smoke, stopped
years ago.
C.
Used to smoke
pack/day for
years.
D.Continue to smoke.
E. Have smoked
F.Smoke only a pipe or cigar.
TEST
PREDICTED
ACTUAL
%
Forced Vital Capacity (FVC) (L)
Forced Expiratory Volume (FEV1) (L)
FEV1
FVC
Forced Expiratory Flow (FEF 25-75) (L/Sec.)
INTERPRETATION:
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KNEE EXAMINATION
RANGE OF MOTION:
Flexion:
Extension:
Crepitus with range of motion testing:
Yes:
No:
DEFORMITIES:
Swelling/Effusion:
With leg in full extension, circumference of thigh 7 cm and 20 cm proximal to superior pole of patella:
L:
R:
TESTS:
McMurray’s (medical meniscus):
Internal Rotation (lateral meniscus) with the foot internally rotated, movement from full flexion to extension:
Medial collateral ligament:
Lateral collateral ligament:
Anterior drawer (anterior cruciate ligament):
Patellar apprehension:
VMO on injured side compared to other:
Hop on each leg:
Squat:
Knee pain on rotation of hips and shoulders with feet together:
Knee pain on rotation of hips and shoulders with feet crossed:
X-rays, 3 views - AP, lateral and sunrise:
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INFORMED CONSENT FOR TREADMILL EXERCISE TEST OF PATIENTS
In order to evaluate the functional capacity of my heart, lungs, and blood vessels, I hereby consent, voluntarily, to perform an exercise test. I understand that I will be questioned and examined by a doctor, and have an electrocardiogram recorded to exclude any apparent contraindications to testing. Exercise will be performed by walking on a treadmill, with the speed and grade increasing every three minutes, until limits of fatigue, breathlessness, chest pain, and/or other symptoms occur to indicate that I have reached my limit. Blood pressure and electrocardiogram will be monitored during the test. The test may be stopped sooner than my own limit if the technician’s observations suggest that it may be unnecessary or unwise to continue.
The risks in performing this test are the risks of physical exercise and include irregular, slow and very rapid heart beats, large changes in blood pressure, fainting, and very rare instances of heart attack. Every effort will be made to minimize these by the preliminary examination and by observations during testing. Emergency equipment and trained personnel are available to deal with unusual situations as they arise.
The information obtained will be treated as confidential and will not be released to anyone without my express written consent. The information may, however, be used for statistical or scientific purpose with my right of privacy retained.
I have read the above, understand it, and all questions have been satisfactorily answered.
Patient’s Signature:
Witness:
Page 7
EXERCISE TOLERANCE TESTING WORKSHEET
Age:
Sex:
MPHR
100%
85%
Medications:
HR
BP
ST DEPRESSION
OTHER EKG CHANGES
SYMPTOMS
Sit
Standing
Hypervent.
Minutes
1
STAGE 1
2
1.7 MPH
3
10% GRADE
4
STAGE 2
5
2.5 MPH
E
6
12% GRADE
X
7
STAGE 3
8
3.4 MPH
R
9
14% GRADE
C
10
STAGE 4
I
11
4.2 MPH
S
12
16% GRADE
13
STAGE 5
14
5.0 MPH
15
18% GRADE
16
STAGE 6
17
5.5 MPH
18
20% GRADE
IMMED.
O
V
Y
TOTAL:
LAST STAGE:
TIME IN LAST STAGE:
POST-EXERCISE P.E.:
MHR:
% OF MHR:
MAX. SYSTOLIC B.P.:
ST:
DOUBLE PRODUCT:
VO2:
R-WAVES: PRE:
POST:
RST:
FUNCTIONAL AEROBIC IMPAIRMENT:
Page 8
AUTHORIZATION TO RELEASE MEDICAL/PSYCHIATRIC/PSYCHOLOGICAL INFORMATION
Patient’s Name
Date of Birth
Social Security Number
TO WHOM IT MAY CONCERN:
I hereby request and authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, or other health care provider that has provided payment, treatment or services to me or on my behalf to furnish to the Oklahoma Police Pension and Retirement System , the Retirement Board, and/or the participating municipality to which I am seeking employment and any representative thereof (collectively, the “System”) any and all records, information and evidence in their possession regarding my injuries, medical history, physical condition, and psychiatric/psychological information, including information related to alcohol or drug abuse, both prior and subsequent to the date below until this authorization expires or until I revoke this authorization. Any or all of such health information is referred to in this authorization as my “protected health information” or “PHI.”
Upon presentation of this authorization, or an exact photocopy thereof, you are directed (1) to permit the personal review, copying or photostatting of such records, information and evidence by the System or (2) to provide copies of such records to the System.
I further understand that, if my PHI is transmitted or maintained electronically (my “electronic PHI”), you or any agent or subcontractor that creates, receives, maintains, or transmits my electronic PHI will implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of my electronic PHI, and you will ensure that any agent (including a subcontractor) to whom you provide my electronic PHI agrees to implement reasonable and appropriate security measures to protect my PHI.
THE INFORMATION AUTHORIZED FOR RELEASE MAY INCLUDE RECORDS WHICH MAY INDICATE THE PRESENCE OF A COMMUNICABLE OR NONCOMMUNICABLE DISEASE.
I hereby acknowledge that the information authorized for release may include information which may be considered information about a communicable or venereal disease, which may include, but is not limited to, a disease such as hepatitis, syphilis, gonorrhea or the human immunodeficiency virus, also known as Acquired Immune Deficiency Syndrome (AIDS).
I also acknowledge that the information that is used or disclosed pursuant to this authorization may be used or redisclosed by the System for purposes of eligibility and benefits determinations and, if presented at a Retirement Board meeting and/or hearing, the information may become part of a public record.
I understand that I may revoke this authorization at any time, in writing, except that revocation will not apply to information already used or disclosed in response to this authorization.
Unless revoked or otherwise indicated, this authorization will expire two years from date of signature.
I hereby release the System from any liability in connection with the release of information pursuant to this authorization.
Signature
Filling out the Oklahoma Police Pension and Retirement System Physical-Medical Examination Form 114 requires careful attention to ensure that the medical history and physical examination results are accurately recorded. This form is a comprehensive document designed to gather a wide range of health information from applicants. It includes sections that must be completed by both the applicant and the examining physician. The steps outlined below will guide you through the process of completing this form, ensuring that all necessary details are provided. This process will facilitate a thorough evaluation of the applicant's health status, which is vital for the decision-making process regarding their pension and retirement benefits.
Upon completion of Form 114, ensure that all the sections are correctly filled and that the document reflects comprehensive and accurate information about the applicant's medical history and current health status. The detailed completion of this form is crucial for a thorough evaluation process in the context of pension and retirement considerations. It is advisable to double-check the information provided for accuracy before submission.
Frequently asked questions about the Oklahoma Form 114:
The Oklahoma Form 114 is designed for police pension and retirement system applicants. It ensures that each applicant undergoes a comprehensive medical examination. This includes a full medical and surgical history, a detailed physical examination, and a variety of tests ranging from visual and audiometric tests to blood work and urinalysis. The goal is to assess the health status of the applicant comprehensively.
Any applicant to the Oklahoma Police Pension and Retirement System is required to complete the Form 114 as part of the application process. The form must be filled out under the guidance of a licensed physician, who will perform the required medical examination and tests.
The Form 114 evaluation includes:
These components are essential for evaluating the overall health and fitness of the applicant.
If a medical condition is identified during the evaluation, it will be documented in the form. Depending on the nature and severity of the condition, it might affect the applicant's eligibility for the pension and retirement system. All significant health issues should be thoroughly documented, outlining the onset, duration, and any symptoms associated with the condition.
Yes, applicants must provide both their personal medical history and any relevant family medical history. This includes information on past injuries, surgeries, diseases, and any medical conditions present in the family. This comprehensive history helps in evaluating the applicant's health risks and potential genetic predispositions.
The information collected through Form 114 is kept confidential and used solely for evaluating the applicant's eligibility for the Oklahoma Police Pension and Retirement System. Applicants also provide consent by signing the form, authorizing the medical examiner to investigate the health statements made within the document, ensuring a level of confidentiality and security concerning the applicant's medical information.
Once the Form 114 is completed by both the applicant and the examining physician, including all the required tests and evaluations, it should be submitted to the Oklahoma Police Pension and Retirement System's designated office or representative. The specific submission details and address are usually provided by the retirement system during the application process.
It is imperative for applicants to the Oklahoma Police Pension and Retirement System to accurately and thoroughly complete Form 114, as it plays a crucial role in the evaluation of their application.
Failing to provide a complete medical and surgical history, including dates. This comprehensive background information is critical for a thorough evaluation.
Not conducting a full physical examination as required. Every part of the mandated physical check-up must be completed for the form to be properly processed.
Omitting visual testing results, both with and without correction. Including tests for binocular vision and color vision is essential for a complete application.
Skipping audiometric testing details, including the decibel level. Hearing tests are a vital component of the assessment.
Leaving out blood work results, such as the Comprehensive Metabolic Profile, Cholesterol, GGTP, and others. Each of these indicators offers crucial health insights.
Forgetting to include urinalysis with microscopic examination. This analysis plays a significant role in detecting a variety of conditions.
Omitting X-ray results, especially if there's a history of back problems or surgery. These insights are vital for assessing candidates adequately.
Not providing results from the T.B. skin test. Given the nature of the position, understanding the applicant's TB status is important.
Overlooking pulmonary function test results. Pulmonary health is essential for the demanding roles usually associated with this form.
Missing exercise tolerance test (Bruce Protocol) results and their interpretation. Such tests provide valuable information regarding an applicant's physical capacity.
By avoiding these common errors and ensuring that all required information is completely and accurately filled out, applicants and physicians can facilitate a smoother review process and avoid unnecessary delays or complications.
When dealing with the Oklahoma Police Pension and Retirement System Physical-Medical Examination Form (Form 114), several other forms and documents are often required to provide a comprehensive overview of an applicant's health status. These documents ensure that the pension board has all the necessary information to make informed decisions regarding an applicant's eligibility for benefits based on their physical and medical condition.
Together, these documents complement the Oklahoma Police Pension and Retirement System Physical-Medical Examination Form (Form 114) by providing a fuller picture of the applicant's health. They ensure thorough consideration of every relevant aspect of an applicant's medical condition, crucial for fair and informed decision-making by the pension board.
The document that the Oklahoma Police Pension and Retirement System mandates for physical and medical examinations bears a significant resemblance to the Federal Aviation Administration (FAA) medical certification form used by pilots. Both documents require a comprehensive medical history, a thorough physical examination, including vision and hearing tests, and specify laboratory tests that include blood work, urinalysis, and chest X-rays. Additionally, both forms ask for information on any previous surgeries, conditions, or disabilities, aiming to assess the applicant's fitness for duty within their respective fields.
Another similar document can be found in the medical evaluation forms used for military enlistment, specifically the Department of Defense Form 2808, "Report of Medical Examination". Like the Oklahoma form, it includes a detailed review of the individual's medical history, a complete physical examination that covers various systems in the body, and specifically outlines the need for visual acuity testing, hearing tests, laboratory tests, and a review of the person's immunization status. These parallels underscore the importance of ensuring an individual's health and fitness for service-oriented roles.
Occupational health and safety regulations often mandate comprehensive workplace physical examinations for employees in hazardous jobs, paralleling the Oklahoma Police Pension and Retirement System's requirements. These occupational health assessments similarly include a detailed medical history, a full physical exam, specific tests for visual and auditory capabilities, and laboratory tests aiming to detect any condition that might impair an employee's ability to safely perform their job duties, highlighting the universal concern for health and safety across physically demanding professions.
Commercial driver's license (CDL) medical examinations required by the Department of Transportation (DOT) also share notable similarities with the examined document. The emphasis on detailed medical history, physical examination, vision and hearing tests, and specific laboratory tests like urinalysis reflects a shared objective of ensuring the safety and well-being of the individual and the public. Both forms serve as critical assessments of fitness for the responsibilities inherent to the role, although the DOT form specifically caters to the unique demands of commercial driving.
The pre-employment physical exams commonly required in the healthcare industry resemble the medical examination form used by the Oklahoma Police Pension and Retirement System. These forms assess overall health and physical ability, including the evaluation of communicable diseases, which is crucial for protecting patients and healthcare workers. Both types of documents aim to ensure that the individuals are physically capable of performing their duties while minimizing the risk of transmitting infections, signifying the high stakes of physical fitness in health-related occupations.
Sports physical examination forms, often required for student-athletes before participating in school-sponsored athletic programs, share objectives with the Oklahoma Police Pension and Retirement System's medical examination form. While focusing on the athlete's ability to safely engage in competitive sports, these forms evaluate the individual's medical history, conduct a physical examination, and perform tests such as hearing and vision screenings, mirroring the comprehensive health evaluation seen in the Oklahoma form. The emphasis on ensuring the individual's physical readiness highlights the universal importance of health assessments across various fields.
The last comparable document is the immigrant visa medical examination forms required by the U.S. Department of State. These forms necessitate a complete medical examination, vaccination verification, and testing for communicable diseases, similar to the Oklahoma Police Pension and Retirement System's form. Although the primary goal is to protect public health, both forms meticulously assess the individual's health status and medical history, ensuring they meet the specific health criteria required for their respective roles or statuses.
When filling out the 114 Oklahoma form, it's essential to follow guidelines carefully to ensure an accurate and complete submission. Pay close attention to the following dos and don'ts:
When navigating the procedures and requirements of the Oklahoma Police Pension and Retirement System Physical-Medical Examination, as outlined in the Form 114, individuals often encounter a variety of misconceptions. Below is an exploration of eight common myths surrounding this form, providing clarity to ensure accurate understanding and compliance.
Only physical fitness matters. While Form 114 places significant emphasis on physical health and capabilities, it equally prioritizes comprehensive health history, including past surgeries, conditions, and even family medical history. This comprehensive approach underlines the importance of overall wellness in addition to physical fitness.
The form is only about current health status. Contrary to this belief, Form 114 requires detailed medical and surgical history. This not only includes the applicant's current health status but also their past medical history, emphasizing the role that past health events may play in determining current fitness for duty.
Visual and hearing tests are secondary. In reality, visual and audiometric testing are essential components of the evaluation. These tests are not mere formalities but critical assessments to ensure that applicants meet the vision and hearing standards necessary for performing their duties effectively.
Drug testing is a formality. The urine drug test required by Form 114 must meet NIDA Standards, indicating the serious approach towards ensuring applicants do not use illegal substances. This requirement underscores the commitment to maintaining a drug-free workplace.
Family medical history is irrelevant. On the contrary, Form 114 asks for family medical history, reflecting the understanding that genetics can play a significant role in an individual's health risk factors. This information can provide valuable insights into potential health risks that might affect the applicant's ability to perform.
Every section must be completed by the applicant. While the applicant must provide thorough information, some sections, especially those requiring medical or lab results, are intended for completion by medical professionals. This division ensures that all information is accurate and evaluated by experts.
Mental health is not a focus. Form 114 inquires about the applicant's history with conditions such as anxiety, depression, or substance abuse, underscoring the importance of mental health alongside physical health in determining fitness for duty.
Misunderstandings about the knee exam. Some believe the knee examination applies to all applicants. However, it specifically requires completion only if there is a history of knee surgery or significant injury, highlighting the personalized approach to assessing an individual's health status.
Dispelling these misconceptions about Form 114 is crucial for applicants to understand the requirements and significance of each section, ensuring a thorough and accurate assessment of their suitability for the Oklahoma Police Pension and Retirement System.
Understanding the 114 Oklahoma form is crucial for applicants and physicians alike, as it's a thorough medical examination document required by the Oklahoma Police Pension and Retirement System. Here are nine key takeaways to navigate this form effectively:
This meticulous approach ensures that all potential health concerns are addressed, providing a clear and comprehensive health profile of each applicant to the Oklahoma Police Pension and Retirement System.
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