Content of Physical Examination

(A) The physical examination shall include inquiry concerning: (1) signs and symptoms of disease or injury; (2) chronic health problems; (3) use of prescribed or non-prescribed medicines or drugs, including alcohol; (4) allergies; (5) prior significant illness and hospitalization; (6) family history; and (7) immunization status. (B) The physical examination shall also include observation concerning: (1) Behavior, which includes state of consciousness, with screening for mental status and active mental health issues, as well as appearance, conduct, tremor and sweating; (2) Signs of trauma and communicable disease; (3) Dental decay, filled and missing teeth. (C) The physical inspection and examination shall be consistent with community standards, with targeted attention to risk factors common among incarcerated individuals, and include prompts for reporting such risk factors, including administration of a substance use disorder and mental health screening tool, such as the U.S. Substance Abuse and Mental Health Services Administration Screening, Brief Intervention, and Referral to Treatment (SBIRT), as well as measurement of vital signs, height, weight and oxygen saturation. (D) Diagnostic Tests. The following diagnostic tests shall be performed on each inmate consistent with the current recommendations of the USPSTF, MHQP or other generally recognized evidence-based, consensus practice recommendations, and as medically appropriate in accordance with the provisions of 105 CMR 205.101: (1) Complete blood count (CBC); (2) Purified protein derivative (PPD) skin test for tuberculosis infection by the Mantoux technique and/or chest film as appropriate; (3) Urine for the detection of glucose, ketones, protein and white blood cells. In males, if the results of the white blood cell test is positive, a test for Chlamydia trachomatis shall be conducted. (4) Female - test for gonorrhea and Chlamydia trachomatis infection; (5) Female - Papanicolaou smear of the uterine cervix; (6) Female - pregnancy test; (7) Mammogram - for all females who have been committed for a term of at least 90 days consistent with current recommendations of the USPSTF; (8) HIV counseling and voluntary HIV testing; (9) Counseling about hepatitis C and voluntary testing for hepatitis C virus infection according to risk assessment and age-based recommendations of the USPSTF and the Centers for Disease Control and Prevention; (10) Other age and gender appropriate laboratory and imaging screening tests consistent with current recommendations of the USPSTF.