AF IMT Form 4321 Reserve Component Health Risk Assessment

AF IMT Form 4321 is a U.S. Air Force IMT (Information Management Tool) form also known as the "Reserve Component Health Risk Assessment". The latest edition of the form was released in February 21, 2003 and is available for digital filing.

Download a PDF version of the AF IMT Form 4321 down below or find it on U.S. Air Force IMT (Information Management Tool) Forms website.

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Reserve Component Health Risk Assessment
(RCHRA)
(This form is subject to the privacy Act of 1974 - Use Blanket PAS - DD Form 2005)
AUTHORITY: 10 U.S.C., 8013, as implemented by Air Force Instruction 48-123.
PURPOSE:
To collect personal information from military Reserve Component (RC) personnel to assess their ability to perform routine fitness testing, their individual
deployment readiness, and overall RC deployment readiness.
ROUTINE USE(S):
To assess the safety of your performing routine fitness testing. To screen for conditions that may interfere with your ability to deploy and meet
Periodic Health Assessment (RCPHA).
DISCLOSURE: Disclosure of this information is required by Title 10,Chapter 51, Section 1004 of the United States Code. Giving false information concerning
Personnel Data
Age
Date of Birth
Name/Rank
SSN
Gender
Home Street Address
City
State
Zip Code
Unit
Duty Section
Base
Duty AFSC
ASC
Primary Email Address
Home Phone
Duty Phone
Civilian Occupation
Air Reserve
Other Specify
Traditional
Active
Individual
(AGR)
(IMA)
Technician
Reservist/Guardsman
Guard/Reserve
Mobilization Augmentee
Traditional ARC: How many days have you performed military duty this year (excluding IDT)?
Days
Are you a family member of an active duty military member entitled to care through military channels?
Yes
No
Racial Background
American Indian/Alaska Native
Asian/Oriental
Black, Hispanic
Black, Non-Hispanic
Pacific Islander
White Hispanic
White, Non-Hispanic
Other
(Specify)
Health Status Questionnaire- Instructions
Mark the appropriate response to each number question and sign the form after reading it carefully. Continue on the reverse side or
attach comments or documentation if necessary. Positive responses which are not fully explained or which may effect your medical
qualifications for continued military duty will require an interview and further documentation. You may also be required to provide
supporting civilian medical and dental documentation for inclusion in your medical records.
NOTE: This information is for official and medically-confidential use only and will not be released to unauthorized persons.
1. Overall Self-Assessment of Health is
Very Good
Excellent
Good
Fair
Poor
2. Are you on a renewable flying or worldwide duty waiver for any medical reason?
Yes
No
3. Do you have any allergies to medications, foods, or airborne substances?
Yes
No
List all known allergies:
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AF IMT 4321, 20030221, V1
Reserve Component Health Risk Assessment
(RCHRA)
(This form is subject to the privacy Act of 1974 - Use Blanket PAS - DD Form 2005)
AUTHORITY: 10 U.S.C., 8013, as implemented by Air Force Instruction 48-123.
PURPOSE:
To collect personal information from military Reserve Component (RC) personnel to assess their ability to perform routine fitness testing, their individual
deployment readiness, and overall RC deployment readiness.
ROUTINE USE(S):
To assess the safety of your performing routine fitness testing. To screen for conditions that may interfere with your ability to deploy and meet
Periodic Health Assessment (RCPHA).
DISCLOSURE: Disclosure of this information is required by Title 10,Chapter 51, Section 1004 of the United States Code. Giving false information concerning
Personnel Data
Age
Date of Birth
Name/Rank
SSN
Gender
Home Street Address
City
State
Zip Code
Unit
Duty Section
Base
Duty AFSC
ASC
Primary Email Address
Home Phone
Duty Phone
Civilian Occupation
Air Reserve
Other Specify
Traditional
Active
Individual
(AGR)
(IMA)
Technician
Reservist/Guardsman
Guard/Reserve
Mobilization Augmentee
Traditional ARC: How many days have you performed military duty this year (excluding IDT)?
Days
Are you a family member of an active duty military member entitled to care through military channels?
Yes
No
Racial Background
American Indian/Alaska Native
Asian/Oriental
Black, Hispanic
Black, Non-Hispanic
Pacific Islander
White Hispanic
White, Non-Hispanic
Other
(Specify)
Health Status Questionnaire- Instructions
Mark the appropriate response to each number question and sign the form after reading it carefully. Continue on the reverse side or
attach comments or documentation if necessary. Positive responses which are not fully explained or which may effect your medical
qualifications for continued military duty will require an interview and further documentation. You may also be required to provide
supporting civilian medical and dental documentation for inclusion in your medical records.
NOTE: This information is for official and medically-confidential use only and will not be released to unauthorized persons.
1. Overall Self-Assessment of Health is
Very Good
Excellent
Good
Fair
Poor
2. Are you on a renewable flying or worldwide duty waiver for any medical reason?
Yes
No
3. Do you have any allergies to medications, foods, or airborne substances?
Yes
No
List all known allergies:
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AF IMT 4321, 20030221, V1
Yes
No
4. (a) Do you regularly take any prescription medication(s)?
Yes
No
(b) Do you regularly take any over the counter medication(s)?
Yes
No
(c) Do you regularly take any dietary supplement(s)?
Medication(s) Name and why taken
5. During the last year have you taken medication or seen a health care provider for any of the following conditions?
Chest pain/angina
Yes
No
Shortness of breath
Yes
No
Anxiety/depression
Yes
No
Inflammatory bowel disease
Yes
No
Seizure Disorder
Yes
No
If you require medications for any of the above, have the medications been listed in block # 5.
Yes
No
(If No please explain below)
Does the use of these medications control your symptoms?
N/A
Yes
No
6. During the last year have you been told that you have high blood pressure?
Yes
No
Yes
No
8. Have you ever had irregular heartbeats that have concerned you?
Yes
No
9. Have you ever had a heart attack?
Yes
No
Yes
No
11. Is there a family history of heart attack in a parent, sibling, aunt or uncle before the age of 55?
Yes
No
(Check all that apply.)
12. Have you been told you have high blood sugar or diabetes? How is it controlled?
Yes
No
Other (Explain)
Insulin
13. Have you been told you have problems with blood cholesterol?
Yes
No
14. Do you use any tobacco products? If no, skip to question 15.
Yes
No
Type- (check all that apply):
Pipe
Cigar
Smokeless
Cigarettes
How many packs of cigarettes per day?
Less than one
One
Two
Three or more
How many years have you been using tobacco products?
Less than one
One-Five
Six-Ten
More than Ten
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AF IMT 4321, 20030221, V1
Date
Name/Rank
SSN
15. Do you ever experience shortness of breath at rest, walking or with only moderate exertion?
Yes
No
16. Have you ever been told you have asthma, bronchospasm, or reactive airway disease?
Yes
No
17. Do you engage in a program of regular aerobic physical fitness 20 minutes 3 times per week?
Yes
No
Light Exercise
Moderate Exercise
Heavy Exercise
18. Do you have a physical condition that prevents you from brisk walking or running for 1 to 3 miles?
Yes
No
19. Has your treating physician placed you on restricted activity?
Yes
No
If yes, explain (include length of time and time of year restrictions apply if known)
20. Do you have any bone, joint, or muscle problems that prevent regular exercise or become bothersome during exercise?
Yes
No
21. Are you on any medications for depression, attention deficit, hyperactivity disorder or any other psychiatric condition?
Yes
No
Yes
No
b. Have you ever felt you ought to cut down on your drinking?
Yes
No
c. Have people annoyed you by criticizing your drinking?
Yes
No
d. Have you ever felt bad or guilty about your drinking?
Yes
No
e. Have you ever had a drink first thing in the morning (eye opener) to steady your nerves or get rid of a hangover?
Yes
No
22. Is there a history of cancer in your family? Check all that apply.
Breast
Colon
Leukemia
No
23. Do you wear prescription glasses or contact lenses? Check all that apply below.
Yes
No
Blurred Vision
Double Vision
Blind Spots
Night Blindness
Glare
Glaucoma
Glasses more than 2 years old
24. Have you had any of the following types of eye surgery (check all that apply)?
Yes
No
RK
PRK
LASIK
Implants
Other Specify:
25. Have you gained or lost more than 15 pounds in the past year that cannot be explained by change in diet and exercise?
Yes
No
26. Have you noticed blood in your stool or significant changes in your bowel habits?
Yes
No
27. Have you been advised to eat a special diet?
Yes
No
28. During the past year have you missed more than 7 days from work due to illness or injury?
Yes
No
29. Do you have a non-military job or hobby which exposes you to loud noise?
Yes
No
30. Do you have a non-military job or hobby which exposes you to hazardous chemicals?
Yes
No
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AF IMT 4321, 20030221, V1
Name and/or type of chemical(s)?
31. Do you use hearing aid(s)?
Yes
No
Yes
No
33. Do you routinely forget to fasten your seat belt?
Yes
No
34. Have you seen a health care provider during this past year?
Yes
No
If yes how many visits:
One - Two
Three - Six
Seven - Ten
More than Ten
Yes
No
Yes
No
Females Only Complete Blocks 37 - 41
37. Are you pregnant?
Yes
No
38. Was your last PAP Smear abnormal?
Yes
No
39. Have you ever had an abnormal breast lump or mammogram?
Yes
No
40. Do you perform self-breast examination (SBE) at least monthly?
Yes
No
Yes
No
Typed or Printed Name Examinee
Signature
Date
Notes:
Typed or Printed Name Physician or Examiner
Signature
Date
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AF IMT 4321, 20030221, V1

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