The 114 Oklahoma form, officially titled as the "Oklahoma Police Pension and Retirement System Physical-Medical Examination," is designed to collect comprehensive medical, surgical, and physical examination data, along with relevant laboratory and testing information for applicants. It encompasses a wide array of health inquiries ranging from complete medical and surgical histories, physical examinations, visual and audiometric tests, to more detailed investigations like blood work, urinalysis, and even specific assessments such as pulmonary function tests and knee examinations. Ensure your application is thorough and accurate by carefully filling out the 114 Oklahoma form by clicking the button below.
Navigating through the intricate details of the Oklahoma Police Pension and Retirement System's physical-medical examination requirement, better known as the 114 Oklahoma form, unveils a comprehensive approach to evaluating the health status of applicants. This procedure mandates an exhaustive collection of health data, starting with a complete medical and surgical history followed by a thorough physical examination. Applicants undergo a variety of tests, including visual and audiometric screenings to assess hearing and sight capabilities, extensive blood work covering a wide range of potential health concerns such as cholesterol levels, liver function, and infectious diseases, among others. Urinalysis, chest and lumbar spine X-rays (conditional upon historical back problems or surgery), a tuberculosis skin test, and pulmonary function tests further expand the evaluation. An exercise tolerance test and a knee examination form, the latter required in cases of previous knee surgery or significant injury, ensure a holistic review of an applicant's physical fitness. Additionally, a urine drug test aligning with NIDA Standards is imperative, underpinning the importance of sobriety in eligible candidates. Through personalized questions regarding past health experiences and family medical history, the form delves deeply into the applicant's health narrative, reinforcing the critical role of transparency and accuracy in the pursuit of safeguarding the well-being of those devoted to law enforcement.
Page 1
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:
Page 3
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:
Page 5
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:
Page 6
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
After acquiring Form 114, Oklahoma Police Pension and Retirement System Physical-Medical Examination, the next steps involve correctly completing it. This form plays a crucial role for applicants in providing comprehensive medical and physical health data crucial for processing. Accuracy and thoroughness are vital when filling out this form to ensure all medical conditions, previous surgeries, and any potential health issues are documented. Following step-by-step instructions makes this process manageable.
After all steps are completed and double-checked for accuracy, the Form 114 should be ready for submission to the appropriate authority or department as directed. It's essential to retain a copy for personal records and follow up with the application process as required.
What is the purpose of the Oklahoma Form 114?
The Oklahoma Form 114 is designed for use within the Oklahoma Police Pension and Retirement System. Its primary purpose is to document a comprehensive physical and medical examination of applicants who are seeking to become part of the Oklahoma police force. This documentation includes medical and surgical history, a complete physical exam, visual and audiometric testing, blood work, and other specific tests like chest X-rays and TB skin tests, among others. Essentially, it ensures that the applicants meet the health standards required for the demanding role of a police officer.
Who needs to complete the Oklahoma Form 114?
This form is required to be completed by applicants to the Oklahoma Police Pension and Retirement System. It necessitates collaboration between the applicant and a qualified physician, who performs the necessary medical examinations and tests, recording their findings on the form. The detailed health screening and physical assessment aim to identify any underlying health issues or limitations that could impede the applicant's ability to perform their duties effectively.
What information is required in the History and Physical with Lab Data section?
The History and Physical with Lab Data section of the Oklahoma Form 114 demands a thorough compilation of the applicant's medical and surgical history, including dates and details of past health issues or treatments. This section also calls for a comprehensive physical examination reporting, including assessments of the applicant's vision, hearing, blood work data (e.g., metabolic profile, cholesterol levels, hepatitis B and C, HIV tests), urinalysis, and chest and lumbar spine X-rays if applicable. Additional tests such as a TB skin test, pulmonary function test, and exercise tolerance test are also required, depending on the applicant's medical history.
What does the Physician Instructions section include?
The Physician Instructions section on the Oklahoma Form 114 offers a detailed outline of the necessary steps and evaluations the examining physician must undertake. It specifies the need for a complete medical and surgical history review, a thorough physical examination, specific laboratory tests covering a wide range of potential health concerns (including infectious diseases and metabolic health), as well as specialized tests such as visual and audiometric screening. This section ensures that the physician adheres to a standardized protocol for evaluating the health and fitness of police pension and retirement system applicants.
How are the lab results submitted with the form?
Lab results should be directly incorporated into the Oklahoma Form 114, with the physician entering the specific findings in the designated sections of the form following the completion of each test. This includes data from blood tests, urinalysis, X-rays, and any other pertinent diagnostic tests mandated by the form's instructions. The physician or medical facility is responsible for ensuring that all results, including copies of lab reports and X-ray images if required, are securely attached to the form upon submission to the relevant authority or department.
Is there a section for personal health declarations by the applicant?
Yes, the Oklahoma Form 114 includes sections where applicants must personally declare their medical history and current health status. These declarations cover a wide range of health-related questions, including past surgeries, hospitalizations, allergic reactions, any history of diseases or injuries to specific body parts, and details concerning the applicant's general health and wellness. These self-reported health declarations assist in painting a comprehensive picture of the applicant's health, supplementing the objective findings from the physical examination and lab tests.
What are the applicant's responsibilities regarding the form?
Applicants are responsible for providing honest and comprehensive answers to the health history questions, obtaining the required medical examination and tests, ensuring the form is fully completed by the examining physician, and submitting the form to the designated reviewing body or department within the Oklahoma Police Pension and Retirement System. They must also sign the form, thereby authorizing medical examiners to investigate any health claims and verify the accuracy of the medical information provided.
What happens after the Oklahoma Form 114 is submitted?
Once the Oklahoma Form 114 is submitted, the information will undergo a review process by officials within the Oklahoma Police Pension and Retirement System or the relevant department overseeing police recruitment. This review aims to assess the applicant's medical fitness and overall suitability for duty. Depending on the findings, further evaluation or follow-up with the applicant might be necessary to clarify or address any health concerns raised by the examination results. Successful completion of this medical and physical evaluation is typically one of the crucial steps towards being admitted into the police force.
Filling out Form 114 for the Oklahoma Police Pension and Retirement System requires careful attention to detail. However, it's easy to make mistakes. Let's explore eight common errors people often make on this form:
Steering clear of these mistakes can lead to a smoother process and avoid potential delays or complications in your application with the Oklahoma Police Pension and Retirement System.
When dealing with the administration of health assessments for personnel within the Oklahoma Police Pension and Retirement System, specific forms and documents are frequently required in addition to the Oklahoma Form 114 to ensure a comprehensive evaluation of an applicant's health and medical history. These documents play a pivotal role in the decision-making process to determine eligibility and suitability for service based on health standards.
Each of these documents fulfills a specific requirement in the process of comprehensive health evaluation, ensuring that individuals are physically and mentally fit for the responsibilities they will undertake. Together with Form 114, these forms facilitate a detailed and efficient assessment process, safeguarding the health interests of the police personnel and the communities they serve.
The 114 Oklahoma form shares similarities with other documents that are pivotal in managing health and safety protocols for employees. One such document is the Pre-employment Physical Examination form used by various industries to ensure that candidates meet the physical requirements of the job. Similar to the 114 Oklahoma form, this document typically requires a comprehensive medical history, physical examination, and may include specific tests like vision and hearing assessments, laboratory tests for blood work, and possibly a drug screen. Both forms serve to verify the health status and physical capability of individuals to perform their roles effectively, aiming to maintain a safe working environment.
Another document that parallels the 114 Oklahoma form is the Annual Physical Examination form, which is common in settings that require employees to maintain a certain level of physical fitness annually. Like the Oklahoma form, the Annual Physical Examination includes detailed physical exams, blood tests, and evaluations for vision and hearing. The emphasis on regular checks, such as pulmonary function tests and exercise tolerance tests, echoes the Oklahoma form’s comprehensive approach to monitoring the health and fitness of personnel, particularly in physically demanding roles.
The Disability Claim Form is another document bearing resemblance to the 114 Oklahoma form, especially in its detailed gathering of medical information to assess a claimant's health status. This form is crucial for individuals seeking to establish eligibility for disability benefits, requiring thorough medical history, evidence of treatment, and current physical condition assessment. Similarities include the need for extensive medical data, tests results (such as blood work and x-rays), and an evaluation of physical capabilities or limitations, highlighting both forms' roles in evaluating health relative to work or functional capacity.
Lastly, the Workers’ Compensation Claim form echoes the 114 Oklahoma form in structure and intent. Employed after an employee sustains a work-related injury or illness, it necessitates a detailed medical examination report, including history, current symptoms, and the results of various tests akin to those listed in the Oklahoma form. This parallel underscores their mutual goal of assessing an individual’s health in the context of their employment, focusing on the impact of work on one’s physical condition and the necessary steps to address any associated medical concerns.
When filling out the 114 Oklahoma form, which is intended for applicants of the Oklahoma Police Pension and Retirement System undergoing a physical-medical examination, there are specific steps to follow and mistakes to avoid to ensure the process is completed accurately and effectively. Below is a breakdown of things you should and shouldn't do.
Do's:
Don'ts:
One common misconception is that the form 114 Oklahoma solely focuses on historical health information. While it does require a detailed medical and surgical history, it also mandates a comprehensive physical examination along with specific tests such as vision and hearing tests, blood work, urinalysis, and even chest X-rays, depending on the applicant's history of back problems or surgery.
Another misunderstanding is that the form is a simple self-reported questionnaire. Despite including sections where the applicant must report past health issues and operations, it requires thorough physical examination results and laboratory assessments to be filled out by a licensed physician, ensuring that the information is accurate and professionally verified.
Some people think that the visual and audiometric tests are standard and do not accommodate individuals with existing impairments. However, these tests are designed to assess the current level of vision and hearing with and without correction, meaning that applicants who use glasses, contact lenses, or hearing aids are still evaluated fairly based on their corrected abilities.
It's also mistakenly believed that the Form 114 doesn't cover potential health risks related to lifestyle choices. In reality, the form includes questions on smoking, asking for detailed information about the quantity and duration of cigarette, pipe, or cigar use, thereby acknowledging the impact of lifestyle on health.
There is a misconception that the urine drug test included in the form is a standard procedure without strict guidelines. However, the form specifies that the urine drug test must meet NIDA Standards, which are comprehensive and federally regulated guidelines ensuring the accuracy and reliability of drug testing procedures.
Some assume that all sections of the Form 114 must be completed by all applicants. In contrast, certain parts of the examination, such as the comprehensive knee examination form, are only required if the applicant has a significant history of knee surgery or injury, illustrating the form's tailored approach to individual health backgrounds.
There's a belief that the form is only concerned with current health status and ignores familial health history. Contrary to this belief, section C of the form specifically asks for family medical history, highlighting the importance of genetic factors in assessing an applicant's overall health and potential risks.
Finally, a common mistake is thinking the form does not address mental health issues. The questionnaire includes a section for the applicant to disclose any history of mental health conditions, including anxiety, depression, or substance abuse, underlining the comprehensive nature of the health assessment.
When filling out and using the Form 114 for the Oklahoma Police Pension and Retirement System, there are several key takeaways to consider for a comprehensive and accurate submission:
In conclusion, the Oklahoma Form 114 process underscores the critical nature of detailed health screenings in evaluating the eligibility of applicants for the Oklahoma Police Pension and Retirement System. Both applicants and physicians must approach the completion of this form with thoroughness, accuracy, and honesty to ensure that all potential health issues are identified and assessed properly.
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