dd2807-1 - REPORT OF MEDICAL HISTORY OMB No. 0704-0413 OMB...

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Unformatted text preview: REPORT OF MEDICAL HISTORY OMB No. 0704-0413 OMB approval expires Mar 31, 2010 (This information is for official and medically confidential use only and will not be released to unauthorized persons.) The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0413). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM AS INDICATED ON PAGE 2. PRIVACY ACT STATEMENT AUTHORITY: 10 USC 504, 505, 507, 532, 978, 1201, 1202, and 4346; and E.O. 9397 (SSAN). PRINCIPAL PURPOSE(S): To obtain medical data for determination of medical fitness for enlistment, induction, appointment and retention for applicants and members of the Armed Forces. The information will also be used for medical boards and separation of Service members from the Armed Forces. ROUTINE USE(S): None. DISCLOSURE: Voluntary; however, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application to enter the Armed Forces. For an Armed Forces member, failure to provide the information may result in the individual being placed in a non-deployable status. WARNING: The information you have given constitutes an official statement. Federal law provides severe penalties (up to 5 years confine- ment or a $10,000 fine or both), to anyone making a false statement. If you are selected for enlistment, commission, or entrance into a commissioning program based on a false statement, you can be tried by military courts-martial or meet an administrative board for discharge and could receive a less than honorable discharge that would affect your future. 1. LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX) 2. SOCIAL SECURITY NUMBER 3. TODAY'S DATE (YYYYMMDD) 4.a. HOME ADDRESS (Street, Apartment No., City, State, and ZIP Code) 5. EXAMINING LOCATION AND ADDRESS (Include ZIP Code) b. HOME TELEPHONE (Include Area Code) 7.a. POSITION (Title, Grade, Component) X ALL APPLICABLE BOXES: b. COMPONENT 6.a. SERVICE Coast Guard c. PURPOSE OF EXAMINATION Active Duty Enlistment Medical Board Navy Reserve Commission Retirement Marine Corps National Guard Retention U.S. Service Academy Army Air Force Separation 8. CURRENT MEDICATIONS (Prescription and Over-the-counter) Other (Specify) b. USUAL OCCUPATION ROTC Scholarship Program 9. ALLERGIES (Including insect bites/stings, foods, medicine or other substance) Mark each item "YES" or "NO". Every item marked "YES" must be fully explained in Item 29 on Page 2. HAVE YOU EVER HAD OR DO YOU NOW HAVE: 10.a. Tuberculosis YES NO 12. (Continued) YES NO f. Foot trouble (e.g., pain, corns, bunions, etc.) b. Lived with someone who had tuberculosis g. Impaired use of arms, legs, hands, or feet c. Coughed up blood d. Asthma or any breathing problems related to exercise, weather, h. Swollen or painful joint(s) e. Shortness of breath i. Knee trouble (e.g., locking, giving out, pain or ligament injury, etc.) j. Any knee or foot surgery including arthroscopy or the use of a scope f. Bronchitis k. Any need to use corrective devices such as prosthetic devices, knee g. Wheezing or problems with wheezing l. Bone, joint, or other deformity pollens, etc. to any bone or joint brace(s), back support(s), lifts or orthotics, etc. h. Been prescribed or used an inhaler m. Plate(s), screw(s), rod(s) or pin(s) in any bone i. A chronic cough or cough at night n. Broken bone(s) (cracked or fractured) j. Sinusitis 13.a. Frequent indigestion or heartburn k. Hay fever b. Stomach, liver, intestinal trouble, or ulcer l. Chronic or frequent colds c. Gall bladder trouble or gallstones 11.a. Severe tooth or gum trouble d. Jaundice or hepatitis (liver disease) b. Thyroid trouble or goiter e. Rupture/hernia c. Eye disorder or trouble f. Rectal disease, hemorrhoids or blood from the rectum d. Ear, nose, or throat trouble g. Skin diseases (e.g. acne, eczema, psoriasis, etc.) e. Loss of vision in either eye h. Frequent or painful urination f. Worn contact lenses or glasses i. High or low blood sugar g. A hearing loss or wear a hearing aid j. Kidney stone or blood in urine h. Surgery to correct vision (RK, PRK, LASIK, etc.) k. Sugar or protein in urine l. Sexually transmitted disease (syphilis, gonorrhea, chlamydia, genital 12.a. Painful shoulder, elbow or wrist (e.g. pain, dislocation, etc.) b. Arthritis, rheumatism, or bursitis warts, herpes, etc.) 14.a. Adverse reaction to serum, food, insect stings or medicine c. Recurrent back pain or any back problem b. Recent unexplained gain or loss of weight d. Numbness or tingling c. Currently in good health (If no, explain in Item 29 on Page 2.) e. Loss of finger or toe DD FORM 2807-1, MAR 2007 d. Tumor, growth, cyst, or cancer DoD exception to SF 93 approved by ICMR, August 3, 2000. PREVIOUS EDITION IS OBSOLETE. Reset Page 1 of 3 Pages Adobe Professional 7.0 LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX) SOCIAL SECURITY NUMBER Mark each item "YES" or "NO". Every item marked "YES" must be fully explained in Item 29 below. HAVE YOU EVER HAD OR DO YOU NOW HAVE: YES NO 15.a. Dizziness or fainting spells b. Frequent or severe headache YES NO 19. Have you been refused employment or been unable to hold a job or stay in school because of: c. A head injury, memory loss or amnesia a. Sensitivity to chemicals, dust, sunlight, etc. d. Paralysis b. Inability to perform certain motions e. Seizures, convulsions, epilepsy or fits c. Inability to stand, sit, kneel, lie down, etc. f. Car, train, sea, or air sickness d. Other medical reasons (If yes, give reasons.) g. A period of unconsciousness or concussion h. Meningitis, encephalitis, or other neurological problems 16.a. Rheumatic fever b. Prolonged bleeding (as after an injury or tooth extraction, etc.) c. Pain or pressure in the chest d. Palpitation, pounding heart or abnormal heartbeat e. Heart trouble or murmur f. High or low blood pressure 17.a. Nervous trouble of any sort (anxiety or panic attacks) b. Habitual stammering or stuttering c. Loss of memory or amnesia, or neurological symptoms d. Frequent trouble sleeping e. Received counseling of any type 20. Have you ever been treated in an Emergency Room? (If yes, for what?) 21. Have you ever been a patient in any type of hospital? (If yes, specify when, where, why, and name of doctor and complete address of hospital.) 22. Have you ever had, or have you been advised to have any operations or surgery? (If yes, describe and give age at which occurred.) 23. Have you ever had any illness or injury other than those already noted? (If yes, specify when, where, and give details.) 24. Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the past 5 years for other than minor illnesses? (If yes, give complete address of doctor, hospital, clinic, and details.) f. Depression or excessive worry g. Been evaluated or treated for a mental condition 25. Have you ever been rejected for military service for any reason? (If yes, give date and reason for rejection.) h. Attempted suicide i. Used illegal drugs or abused prescription drugs 18. FEMALES ONLY. Have you ever had or do you now have: a. Treatment for a gynecological (female) disorder b. A change of menstrual pattern 26. Have you ever been discharged from military service for any reason? (If yes, give date, reason, and type of discharge; whether honorable, other than honorable, for unfitness or unsuitability.) d. First day of last menstrual period (YYYYMMDD) 27. Have you ever received, is there pending, or have you ever applied for pension or compensation for any disability or injury? (If yes, specify what kind, granted by whom, and what amount, when, why.) e. Date of last PAP smear (YYYYMMDD) 28. Have you ever been denied life insurance? c. Any abnormal PAP smears 29. EXPLANATION OF "YES" ANSWER(S) (Describe answer(s), give date(s) of problem, name of doctor(s) and/or hospital(s), treatment given and current medical status.) NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL PERSONNEL ONLY." DD FORM 2807-1, MAR 2007 Reset Page 2 of 3 Pages LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX) SOCIAL SECURITY NUMBER 30. EXAMINER'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician/practitioner shall comment on all positive answers in questions 10 - 29. Physician/practitioner may develop by interview any additional medical history deemed important, and record any significant findings here.) a. COMMENTS b. TYPED OR PRINTED NAME OF EXAMINER (Last, First, Middle Initial) DD FORM 2807-1, MAR 2007 d. DATE SIGNED (YYYYMMDD) c. SIGNATURE Reset Page 3 of 3 Pages ...
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This note was uploaded on 10/25/2011 for the course N S 000 taught by Professor Kopke during the Spring '10 term at University of Texas.

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