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Unformatted text preview: 1. DATE OF EXAMINATION (YYYYMMDD) REPORT OF MEDICAL EXAMINATION 2. SOCIAL SECURITY NUMBER PRIVACY ACT STATEMENT AUTHORITY: 10 USC 504, 505, 507, 532, 978, 1201, 1202, and 4346; and E.O. 9397. 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. 3. LAST NAME - FIRST NAME - MIDDLE NAME (SUFFIX) 6. GRADE 7. DATE OF BIRTH (YYYYMMDD) 8. AGE 4. HOME ADDRESS (Street, Apartment Number, City, State and ZIP Code) 10.a. RACIAL CATEGORY (X one or more) 9. SEX Female American Indian or Alaska Native Male b. ETHNIC CATEGORY Black or African American Asian White 11. TOTAL YEARS GOVERNMENT 12. AGENCY (Non-Service Members Only) SERVICE b. CIVILIAN a. MILITARY Native Hawaiian or Other Pacific Islander b. TOTAL FLYING TIME 15.a. SERVICE c. PURPOSE OF EXAMINATION Army b. COMPONENT Navy Marine Corps Air Force Active Duty Reserve National Guard Hispanic/Latino Not Hispanic/ Latino 13. ORGANIZATION UNIT AND UIC/CODE 14.a. RATING OR SPECIALTY (Aviators Only) Coast Guard 5. HOME TELEPHONE NUMBER (Include Area Code) c. LAST SIX MONTHS Enlistment Medical Board Commission Retirement Retention U.S. Service Academy Separation 16. NAME OF EXAMINING LOCATION, AND ADDRESS (Include ZIP Code) ROTC Scholarship Program Other CLINICAL EVALUATION (Check each item in appropriate column. Enter "NE" if not evaluated.) Nor- Abmal norm NE 17. Head, face, neck, and scalp 18. Nose 44. NOTES: (Describe every abnormality in detail. Enter pertinent item number before each comment. Continue in item 73 and use additional sheets if necessary.) 19. Sinuses 20. Mouth and throat 21. Ears - General (Int. and ext. canals/Auditory acuity under item 71) 22. Drums (Perforation) 23. Eyes - General (Visual acuity and refraction under items 61 - 63) 24. Ophthalmoscopic 25. Pupils (Equality and reaction) 26. Ocular motility (Associated parallel movements, nystagmus) 27. Heart (Thrust, size, rhythm, sounds) 28. Lungs and chest (Include breasts) 29. Vascular system (Varicosities, etc.) 30. Anus and rectum (Hemorrhoids, Fistulae) (Prostate if indicated) 31. Abdomen and viscera (Include hernia) 32. External genitalia (Genitourinary) 33. Upper extremities 34. Lower extremities (Except feet) 35. Feet (See Item 35 Continued) 36. Spine, other musculoskeletal 37. Identifying body marks, scars, tattoos 38. Skin, lymphatics 39. Neurologic 40. Psychiatric (Specify any personality deviation) 41. Pelvic (Females only) 35. FEET (Continued) (Circle category) 42. Endocrine 43. DENTAL DEFECTS AND DISEASE (Please explain. Use dental form if completed by dentist. If dental examination not done by Acceptable dental officer, explain in Item 44.) Not Acceptable Class DD FORM 2808, OCT 2005 Normal Arch Mild Pes Cavus Moderate Pes Planus Severe DoD exception to SF 88 approved by ICMR, August 3, 2000. PREVIOUS EDITION IS OBSOLETE. Reset Asymptomatic Symptomatic Page 1 of 3 Pages FormFlow/Adobe Professional 6.0 Adobe Professional 7.0 LAST NAME - FIRST NAME - MIDDLE NAME (SUFFIX) SOCIAL SECURITY NUMBER LABORATORY FINDINGS 45. URINALYSIS 46. URINE HCG a. Albumin 47. H/H 48. BLOOD TYPE b. Sugar TESTS HIV SPECIMEN ID LABEL RESULTS DRUG TEST SPECIMEN ID LABEL 49. HIV 50. DRUGS 51. ALCOHOL 52. OTHER a. PAP SMEAR b. c. MEASUREMENTS AND OTHER FINDINGS 53. HEIGHT 54. WEIGHT 55. MIN WGT - MAX WGT MAX BF % 56. TEMPERATURE 57. PULSE lbs. 59. RED/GREEN (Army Only) 58. BLOOD PRESSURE a. 1ST b. 2ND SYS. SYS. SYS. DIAS. DIAS. 60. OTHER VISION TEST c. 3RD DIAS. 61. DISTANT VISION 62. REFRACTION BY AUTOREFRACTION OR MANIFEST Corr. to 20/ Right 20/ By EX S. CX Right 20/ Corr. to 20/ by By Left 20/ Corr. to 20/ 64. HETEROPHORIA (Specify distance) ES 63. NEAR VISION S. CX Left 20/ Corr. to 20/ by R.H. L.H. Prism Conv CT Prism div. NPR PD 65. ACCOMMODATION 66. COLOR VISION (Test used and result) 67. DEPTH PERCEPTION (Test used and score) AFVT Right PIP Uncorrected Left /14 69. NIGHT VISION (Test used and score) 68. FIELD OF VISION Corrected 70. INTRAOCULAR TENSION O.D. 71a. AUDIOMETER Unit Serial Number Date Calibrated (YYYYMMDD) HZ 500 1000 2000 O.S. 72a. READING ALOUD TEST 71b. Unit Serial Number Date Calibrated (YYYYMMDD) 3000 4000 6000 HZ Right 1000 2000 Right Left 500 3000 4000 SAT 6000 Left UNSAT 72b. VALSALVA SAT UNSAT 73. NOTES (Continued) AND SIGNIFICANT OR INTERVAL HISTORY (Use additional sheets if necessary.) DD FORM 2808, OCT 2005 Reset Page 2 of 3 Pages LAST NAME - FIRST NAME - MIDDLE NAME (SUFFIX) SOCIAL SECURITY NUMBER 74.a. EXAMINEE/APPLICANT (check one) 75. I have been advised of my disqualifying condition. a. SIGNATURE OF EXAMINEE IS QUALIFIED FOR SERVICE b. DATE (YYYYMMDD) IS NOT QUALIFIED FOR SERVICE b. PHYSICAL PROFILE U P L H E S X PROFILER INITIALS DATE (YYYYMMDD) 76. SIGNIFICANT OR DISQUALIFYING DEFECTS ITEM NO. ICD CODE MEDICAL CONDITION/DIAGNOSIS PROFILE SERIAL RBJ DATE (YYYYMMDD) QUALIFIED DISQUALIFIED EXAMINER INITIALS WAIVER RECEIVED SERVICE DATE (YYYYMMDD) 77. SUMMARY OF DEFECTS AND DIAGNOSES (List diagnoses with item numbers) (Use additional sheets if necessary.) 78. RECOMMENDATIONS - FURTHER SPECIALIST EXAMINATIONS INDICATED (Specify) (Use additional sheets if necessary.) 79. MEPS WORKLOAD (For MEPS use only) WKID ST 80. MEDICAL INSPECTION DATE DATE (YYYYMMDD) HT WT %BF INITIAL MAX WT HCG WKID QUAL ST DISQ 81.a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER b. SIGNATURE 84.a. TYPED OR PRINTED NAME OF REVIEWING OFFICER/APPROVING AUTHORITY PHYSICIAN'S SIGNATURE b. SIGNATURE 83.a. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN (Indicate which) INITIAL b. SIGNATURE 82.a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER DATE (YYYYMMDD) b. SIGNATURE 85. This examination has been administratively reviewed for completeness and accuracy. a. SIGNATURE b. GRADE c. DATE (YYYYMMDD) 87. NUMBER OF ATTACHED SHEETS 86. WAIVER GRANTED (If yes, date and by whom) YES NO DD FORM 2808, OCT 2005 Reset Page 3 of 3 Pages ...
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