LIFE SCIENCE REPORT

72-Hour History – General Information

Today’s Date:

Date of Mishap:

Date and time of YOUR involvement with the MDS, AGE or vehicle ____________

Work / Rest Data:

1. Hours worked in last: 24 hrs:_____ 48 hrs:_____ 72 hrs:_____

2. Hours continuously on duty prior to mishap:_____

3. Hours continuously awake prior to mishap:_____

4. Hours between last meal and mishap:_____

Flying Data (if applicable):

Two most recent flights:

Date: Type aircraft: Duration:
Date: Type aircraft: Duration:

Mission Times:
Brief: Step: Taxi: Takeoff: Land:
Mission Profile:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Mission Times:
Brief: Step: Taxi: Takeoff: Land:
Mission Profile:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

*Complete the following if you are giving this statement on a day other than the day of the mishap*

Medications taken TODAY, including dosage and time:

_______________________________________

________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____
 Day of the Mishap

How many hours did you sleep prior to the mishap:_____

Rate your sleep quality (Circle One): Very Poor / Poor / Average / Good / Very Good

Was the sleep continuous or broken?

Describe______________________________________________________________________
_______

Time departed for work:________ Time reported for duty:________

Time of incident (or your involvement):________ Time released from duty day:________

List all food and beverages 1 hour prior to the time of mishap
____________________________________________________________________________________
____________________________________________________________________________________

List all food and beverages 1-4 hours prior to the time of mishap
____________________________________________________________________________________
____________________________________________________________________________________

List all food and beverages 4-8 hours prior to the time of mishap
________________________________________________________________________________
____________________________________________________________________________________
____

List all food and beverages 8-12 hours prior to the time of mishap
________________________________________________________________________________
____________________________________________________________________________________
____

List any medications and/or supplements used within 12 hrs prior to the mishap (include over-the-
counter)
________________________________________________________________________________
____
Time taken:_________

Any alcohol in the 24 hrs prior to the mishap? Yes / No

Times____________ Amount___________________Type:_________________

Any caffeine and/or energy drink prior to the mishap? Yes / No

Time/Amount_______/______Type:_________

Any tobacco prior to the mishap? Yes / No Time/Amount_______/______Type: _________

Exertion within 12 hours of mishap: Very Light / Light / Strenuous / Very Strenuous/ Extremely
Strenuous
 Additional Info/Comments:
______________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

1 Day Prior to Mishap

How many hours did you sleep during the sleep cycle that started this day? _________

Rate your sleep quality (Circle One): Poor / Somewhat Poor / Average / Good / Very Good

Was the sleep continuous or broken? If broken,

explain_______________________________________

Time departed for work: _________ Time reported for duty: _________

Breakfast: Yes / No Time:

Meal:______________________________________________

Morning activities:
_____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Lunch: Yes / No Time:

Meal:______________________________________________

Afternoon activities:
___________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Dinner: Yes / No Time:

Meal:______________________________________________

Evening activities:
_____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Medications/supplements used today, to include over the counter (OTC)? Yes / No Time
taken:_______
Medications and/or supplements - names and amounts taken:
__________________________________
____________________________________________________________________________________
____________________________________________________________________________________
 Any alcohol this day/night? Yes / No Times/Amount_______/______Type:_____________

Caffeine and/or energy drinks? Yes / No Times/Amount_______/______Type:_________

Exertion this day (circle): Very Light / Light / Strenuous / Very Strenuous / Extremely Strenuous
Type of exertion/exercise:
______________________________________________________________

Mission Times (for flyers): Brief: Step: Taxi: Takeoff: Land:

Mission Profile:

Additional Info/Comments:
______________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

2 Days Prior to Mishap

How many hours did you sleep during the sleep cycle that started this day? _________

Rate your sleep quality (Circle One): Poor / Somewhat Poor / Average / Good / Very Good

Was the sleep continuous or broken? If broken,

explain_______________________________________

Time departed for work: _________ Time reported for duty: _________

Breakfast: Yes / No Time:

Meal:______________________________________________

Morning activities:
_____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Lunch: Yes / No Time:

Meal:______________________________________________

Afternoon activities:
___________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Dinner: Yes / No Time:

Meal:______________________________________________
 Evening activities:
_____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Medications/supplements used today, to include over the counter (OTC)? Yes / No Time
taken:_______
Medications and/or supplements - names and amounts taken:
__________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Any alcohol this day/night? Yes / No Times/Amount_______/______Type:_____________

Caffeine and/or energy drinks? Yes / No Times/Amount_______/______Type:_________

Exertion this day (circle): Very Light / Light / Strenuous / Very Strenuous / Extremely Strenuous
Type of exertion/exercise:
______________________________________________________________

Mission Times (for flyers): Brief: Step: Taxi: Takeoff: Land:

Mission Profile:

Additional Info/Comments:
______________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

3 Days Prior to Mishap

How many hours did you sleep during the sleep cycle that started this day? _________

Rate your sleep quality (Circle One): Poor / Somewhat Poor / Average / Good / Very Good

Was the sleep continuous or broken? If broken,

explain_______________________________________

Time departed for work: _________ Time reported for duty: _________

Breakfast: Yes / No Time:

Meal:______________________________________________

Morning activities:
_____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
 Lunch: Yes / No Time:
Meal:______________________________________________

Afternoon activities:
___________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Dinner: Yes / No Time:

Meal:______________________________________________

Evening activities:
_____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Medications/supplements used today, to include over the counter (OTC)? Yes / No Time
taken:_______
Medications and/or supplements - names and amounts taken:
__________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Any alcohol this day/night? Yes / No Times/Amount_______/______Type:_____________

Caffeine and/or energy drinks? Yes / No Times/Amount_______/______Type:_________

Exertion this day (circle): Very Light / Light / Strenuous / Very Strenuous / Extremely Strenuous
Type of exertion/exercise:
______________________________________________________________

Mission Times (for flyers): Brief: Step: Taxi: Takeoff: Land:

Mission Profile:

Additional Info/Comments:
______________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
 7-Day History

The 7-day history is less detailed than the 72-hour history. Please note any significant life events that
have occurred over the past week (e.g. selected for promotion, death in family, work schedules, sorties
flown, marriage difficulties, financial difficulties, days off, vacation/leave, illness, etc.) Include caffeine,
meds, alcohol, tobacco, exercise and hours slept.

Mishap day:
Date/Notes:__________________________________________________________________________
____________________________________________________________________________________
1 day prior to mishap:
Date/Notes:__________________________________________________________________________
____________________________________________________________________________________
2 days prior to mishap:
Date/Notes:__________________________________________________________________________
____________________________________________________________________________________
3 days prior to mishap:
Date/Notes:__________________________________________________________________________
____________________________________________________________________________________
4 days prior to mishap:
Date/Notes:__________________________________________________________________________
____________________________________________________________________________________
5 days prior to mishap:
Date/Notes:__________________________________________________________________________
____________________________________________________________________________________
6 days prior to mishap:
Date/Notes:__________________________________________________________________________
____________________________________________________________________________________
7 days prior to mishap:
Date/Notes:__________________________________________________________________________
____________________________________________________________________________________

During the 7 days prior to the mishap:

Where had you traveled?
_______________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Duty schedule: Light / Normal / Hectic

Had your sleep/wake cycle changed recently (time zone or shift change)? Yes / No If Yes, describe.
____________________________________________________________________________________
____________________________________________________________________________________

Average number of hours slept per night in the 7 days leading up to the mishap.___________________

Extra duties and any education programs you may have participated in (describe):
__________________
____________________________________________________________________________________
____________________________________________________________________________________

Lifestyle Data

Was your food and fluid intake during the 24 hours prior to the mishap characteristic of your normal
eating/fluid intake habits? Yes / No If No, explain___________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Were you on a special diet? Yes / No If yes, what type (weight loss/maintenance, weight gain,
low carb, Adkins, South Beach, etc)?
_________________________________________________________
____________________________________________________________________________________

Do you use tobacco? Yes / No If so, what types?________________ How much daily?
____________

How long have you used tobacco? ________ Have your tobacco use habits changed recently?
_______
____________________________________________________________________________________
____________________________________________________________________________________

Alcohol consumption: What are your normal drinking habits?

Beers per week _______ Glasses of wine per week _______ Hard drinks per week
_______

Had your drinking habits changed recently? Yes / No

If yes, how? ___________________________________________________________________

____________________________________________________________________________________

Other significant lifestyle issues or comments:

________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____
 In the Past 3 Months
Have you experienced any of the below listed? (circle all that apply):

Injury/illness of significance or requiring hospitalization

Other personal health problems/concerns
Death of spouse or close family member
Serious illness of spouse or close family member
Divorce
Promotion
Demotion
Pregnant OR pregnant spouse
New child
Family problems/concerns
PCS
New job/new job responsibilities
New (or changed) diet plan
Legal problems
Money/financial problems or stresses
Start/stop school

Any other life stressors prior to the mishap or your involvement?

___________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
___

Other comments:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________