Fill - Free fillable THEUNITEDMETHODISTCHURCH MEDICALSUMMARYREPORTOFMINISTERIALCANDIDATE Form103 Candidates (The United Methodist Church Michigan Conference) PDF form

THEUNITEDMETHODISTCHURCH

MEDICALSUMMARYREPORTOFMINISTERIALCANDIDATE

Form103

Candidate’s

Name:_____________________________________________________________

TotheBoardofOrdainedMinistry:

Pleaseindicatehere,thename/addressoftheboardofficerwhowillreceivethisreport.

Name:

Address:

CONSENTFORTHERELEASEOF

CONFIDENTIALINFORMATION–COMPLETEDBYCANDIDATE

CandidateName:_____________________________________ BirthDate:_______________________

Iherebyauthorizeanddirect______________________________________(physician)todisclosetothe

______________________________(annualconference)BoardofOrdainedMinistrythefollowinginformationwith

regardtotherecordsof______________________________(candidate)forthepurposeofevaluationbyTheUnited

MethodistChurchforentranceintoministry.

I,theundersigned,understandthatImayrevokethisconsentatanytimeexcepttotheextentthataction

hasbeentakeninrelianceuponit.Thisconsentwillexpiresixty(60)daysafterthedatetreatmentis

terminatedunlessanotherdateisspecified.

Iunderstandthattheinformationrequestedmaybedisclosedfromrecordswhoseconfidentialityis

otherwiseprotectedbyfederalaswellasstatelaw.Anyoftheaboverequestedinformationmayinclude

resultsofalcohol/drug(substance)abuseand/ordiagnosisandtreatmentofpsychologicaldisorders,as

wellasHIVstatus.

Tothepartyreceivingthisinformation:Thisinformationhasbeendisclosedtoyoufromrecordswhose

confidentialityisprotectedbyfederallaw.Federalregulations(42CFRPart2)prohibityoufrommaking

anyfurtherdisclosureofitwithoutthespecificwrittenconsentofthepersontowhomitpertains,oras

otherwisepermittedbysuchregulations.Ageneralauthorizationforthereleaseofmedicalorother

informationisnotsufficientforthispurpose.

Signature of Candidate Date

Witness

Date

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

1011 Northcrest Rd., Lansing, MI 48906

SUMMARYREPORT–COMPLETEDBYPHYSICIAN

Commentsforphysician:

Completethesummaryreport.TheUnitedMethodistChurchassumesyouarecompletingthisinformation

basedonacurrentphysicalexaminationofthecandidate.Screeningguidelinesareprovidedforreference

asneeded.

ThispersonisacandidateforministryinTheUnitedMethodistChurch.Amongotherrequirements,this

includesbeingabletotypicallyworkafull‐timeweek–withperiodicweeksrequiringlongerworkhours.

Thoseservinginministrywillencountersituationsthatrequiretheabilitytocopewithconflictandstress.

Job‐relatedtasksrangefromofficeworkandtravelingfromsitetositetocommunicatingwithandrelating

toavarietyofpeopleandmanagingmultipletaskssimultaneously,amongotherresponsibilities.

Candidate’sName:_____________________________________________________________

DateofPhysicalExam:__________________________________________________________

CheckOne:

____ BasedonthephysicalexamIcompleted,thiscandidateappearstobehealthy.Ihavenoconcerns

abouthis/herphysicalfitnessforministry.

_____ BasedonthephysicalexamIcompleted,thiscandidatehassomehealthconcernsthatare

summarizedbelow.

SummaryofConcerns:

Typicaltreatment(s)forthisconditioncouldpotentiallyinclude(medication,surgery,lifestyle

modification,interventionbyspecialist,frequentmonitoring,etc.):



Questionstoask,orconversationthatacommitteemighthave,toaddresstheseconcernscould

include:



Examining Provider:

Address:

Phone:

Fax:

Signature: Date:



STAMP



EXAMINATIONSTANDARDS*

Asapartoftheministryapplicationprocess,TheUnitedMethodistChurchrequireseachcandidateto

“presentasatisfactorycertificateofgoodhealth”byaphysicianontheprescribedform.Disabilitiesarenot

tobeconstruedasunfavorablehealthfactorswhenapersonwithdisabilityiscapableofmeetingthe

professionalstandardsandisabletorendereffectiveservice….(TheBookofDiscipline,¶¶315.6c,324.8,

347.3,357.7,355.3,368.5).

Thefollowinglistsshowstandardscreeningpracticestobeconsideredinanassessmentofphysicalhealth.

Additionally,thephysicianmaychoosetomakerecommendationstothecandidateasneeded.Whilethe

candidate’sphysicianshouldmakethefinaldeterminationregardingtheneedforspecificmedicaltestsas

relatedtotheoverallhealthandneedsofthecandidate,TheUnitedMethodistChurchseeksasummary

reportfromthephysicianuponcompletionofaphysicalexaminationofthecandidatethatprovidesan

assessmentofthecandidate’sphysicalabilitytoperformtherequiredworkofministry.

NOTE:DONOTRECORDSCREENINGRESULTSONTHISFORM.

Screening

Heightandweight(periodically)

Bloodpressure

Alcoholandtobaccouse

Depression(ifappropriatefollow‐upisavailable)

Diabetesmellitus(patientswithhypertension)

Dyslipidemia(totalandHDLcholesterol):men≥35y;menorwomen≥20ywhohave

cardiovascularriskfactors;measureevery5yifnormal

Colorectalcancerscreening(menandwomen50‐75y)

Mammogramevery1to2yforallwomen≥40y.EvaluationforBRCA testinginhigh‐riskwomen

only.

Papanicolaoutest(atleastevery3yuntilage65y)

Chlamydialinfection(sexuallyactivewomen≤25yandoldera

‐riskwomen)

RoutinevoluntaryHIVscreening(ages13‐64y)

Bonemineraldensitytest(women≥65y anda

‐riskwomen60‐64y)

AAAscreening(onetimeinmen65‐75ywhohaveeversmoked)

Counseling—SubstanceAbuse

Tobaccocessationcounseling

Alcoholmisuse:briefbehavioralcounseling;alcoholabuse:referralforspecialtytreatmen

Counseling—DietandExercise

Behavioraldietarycounselinginpatientswithhyperlipidemia,risksforCHDandotherdie

‐related

chronicdisease

Regularphysicalactivity(atleast30minutesperdaymostdaysoftheweek)

Intensivecounseling/behavioralinterventionsforobesepatients



AAA = abdominal aortic aneurysm; BRCA = breast cancer susceptibility gene; CHD = coronary heart disease.

* Based on recommendations from the U.S. Preventive Services Task Force.



KeyPoints

 TheU.S.PreventiveServicesTaskForcerecommendsroutineperiodicscreeningforhypertension,

obesity,dyslipidemia(men≥35years),osteoporosis(women≥65years),abdominalaorticaneurysm

(one‐time‐screening),depression,andHIVinfection.

 TheU.S.PreventiveServicesTaskForcerecommendsroutineperiodicscreeningforcolorectalcancer

(persons50‐74yearsofage),breastcancer(women≥40years),andcervicalcancer.

 TheU.S.PreventiveServicesTaskForcerecommendsthatallpregnantwomenbescreenedfor

asymptomaticbacteriuria,iron‐deficiencyanemia,hepatitisBvirus,andsyphilis.

 TheU.S.PreventiveServicesTaskForcerecommendsagainstscreeningforhemochromatosis;carotid

arterystenosis;coronaryarterydisease;herpessimplexvirus;ortesticular,ovarian,pancreatic,or

bladdercancer.

 Outsideofprenatal,preconception,andnewborncare,genetictestingshouldnotbeperformedin

unselectedpopulationsbecauseoflowerclinicalvalidity;potentialforfalsepositives;andpotentialfor

harm,including“geneticlabeling.”

 Forpatientsforwhomgenetictestingmaybeappropriate,referralforgeneticcounselingshouldbe

providedbeforeandaftertesting.

 Ahumanpapillomavirusvaccineseriesisindicatedinfemalesages9through26years,regardlessof

sexualactivity,forpreventionofcervicalcancer.

 Asingledoseoftetanus‐diphtheria–acellularpertussis(Tdap)vaccineshouldbegiventoadultsages19

through64yearstoreplacethenexttetanus‐diphtheriatoxoid(Td)booster.

 Azoster(shingles)vaccineisgiventoallpatients60yearsandolderregardlessofhistoryofprior

shinglesorvaricellainfection.

 Asymptomaticadultswhoplantobephysicallyactiveattherecommendedlevelsdonotneedto

consultwithaphysicianpriortobeginningexerciseunlesstheyhaveaspecificmedicalquestion.

 Smokingstatusshouldbedeterminedforallpatients.

 Patientswhowanttoquitsmokingshouldbeofferedpharmacologictherapyinadditiontocounseling,

includingtelephonequitlines.

 Routinescreeningisrecommendedtoidentifypersonswhosealcoholuseputsthematrisk.

 Formanagementofalcoholabuseanddependence,referralforspecialtytreatmentisrecommended;

formanagementofalcoholmisuse,briefbehavioralcounselingmaybeuseful.

 Cluesforchemicaldependencyincludeunexpectedbehavioralchanges,acuteintoxication,frequentjob

changes,unexplainedfinancialproblems,familyhistoryofsubstanceabuse,frequentproblemswith

lawenforcementagencies,havingapartnerwithsubstanceabuse,andmedicalsequelaeofdrugabuse.

 CondomusereducestransmissionofHIV,Chlamydia,gonorrhea,Trichomonas,herpesvirus,and

humanpapillomavirus.

 Itisimportanttoaskaboutdomesticviolencewhenpatientspresentwithsymptomsorbehaviorsthat

maybeassociatedwithabuse.

 Whenanabusivesituationisidentified,addressimmediatesafetyneeds.



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