47QFWA22R0008 Revised Appendix D - DD Form 2807-2.pdf

CUI (when filled in)

CUI (when filled in)

PREVIOUS EDITION IS OBSOLETE.

Controlled by: OUSD(P&R) CUI Category: HLTH, PRVCY

LDC: FEDCON

POC: 703-695-5527

DD FORM 2807-2, DEC 2021

ACCESSIONS MEDICAL HISTORY REPORT

OMB No. 0704-0413

OMB Approval Expires:

20241031

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, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dodinformationcollections@mail.mil. 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 ADDRESS.

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C.§136, Under Secretary of Defense for Personnel and Readiness; 10 U.S.C. Subtitle A, General Military Law, Part II, Personnel (Chapter 31, Enlistments and Chapter 33, Original Appointments of Regular Officers in Grades Above Warrant Officer Grades); 10 U.S.C. 3013, Secretary of the Army; 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 8013, Secretary of the Air Force; DoD Directive (DoDD) 1145.02E, United States Military Entrance Processing Command (USMEPCOM); DoD Instruction (DoDI) 1304.02, Accession Processing Data Collection Forms; DoDI 1304.12E, DoD Military Personnel Accession Testing Programs; DoDI 1304.26, Qualification Standards for Enlistment, Appointment and Induction; DoDI 6130.03, Medical Standards for Appointment, Enlistment, or Induction in the Military Services;

DoD Manual 1145.02, Military Entrance Processing Station (MEPS); USMEPCOM Regulation 680–3, Entrance Processing and Reporting System Management; and E.O. 9397 (SSN), as amended.

PURPOSE: 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): The Routine Uses are listed in the system of records notice found at: https://www.federalregister.gov/documents/2021/04/21/2021-08286/privacy-act-of-1974-system-of-records

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 confinement or $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 may be subject to prosecution under the Uniform Code of Military Justice or to administrative separation proceedings for discharge, and could receive a less than honorable discharge.

SECTION I – APPLICANT INFORMATION

1. LAST NAME – FIRST NAME – MIDDLE INITIAL (Suffix) 2. AGE 3. DATE OF BIRTH

(YYYYMMDD)

4.a. SOCIAL SECURITY NUMBER 4.b. DoD ID NUMBER

(If applicable)

5. (X each item)

a. SEX (at birth)

Male

Female

b. GENDER

Male

Female

6.a. SERVICE PROCESSING FOR (X as applicable)

Army Space Force

Navy Marine Corps

Air Force Coast Guard Other:

6.b. COMPONENT (X as applicable)

Regular Reserve National Guard

7. PURPOSE OF EXAMINATION (X as applicable)

Enlistment U.S. Service Academy

Commission ROTC Scholarship Other:

8. POSITION (If current Federal Employee) (Job Title, Grade, Component)

SECTION II - APPLICANT (OR PARENT/GUARDIAN) AUTHORIZATION STATEMENT

• I Have read and understand the warning and penalties that are associated with providing a false statement.

• I Agree that all protected health information and personally identifiable information (PHI/PII) or data disclosed by myself or others on my behalf with my consent during the accession process is no longer protected by federal Health Insurance Portability and Accountability Act (HIPAA) Privacy Rules and may be further disseminated as needed.

• I Authorize release of medical records and information relating to grades, performance, individual education plans, and disciplinary proceedings. Under the Family

Educational Rights and Privacy Act (FERPA), United States Military Entrance Processing Command (USMEPCOM)/Department of Defense Medical Examination Review Board (DoDMERB) is authorized to receive all of my education/disciplinary records for evaluation of my suitability for Military Service.

• I Understand that a medical examination is part of the accession evaluation, may require several visits to the Military Entrance Processing Station (MEPS), or DoDMERB contracted medical center. I may have blood work and/or other medical tests, procedures such as cerumen removal, and/or specialty consultations performed as part of my processing.

• I Understand that the results of the examination, tests, and consults are not performed as part of an individual healthcare treatment plan, but will be reviewed and considered as part of my accession application file.

• I Understand that the MEPS/DoDMERB medical staff are not my healthcare providers. If I do not receive notice of an abnormal result of a test or a consultation, I am not to assume that the result is normal. Furthermore, if any test or consultation results are abnormal, then I am responsible for obtaining those results from the MEPS/DoDMERB contracted medical center. I am also responsible for any necessary follow-up evaluations and/or treatment. If I am notified to return to the MEPS/DoDMERB contracted medical center to discuss medical results, it is my responsibility to take quick action to return to the MEPS/DoDMERB contracted medical center.

• I Understand that neither USMEPCOM nor DoDMERB are financially responsible for costs associated with any necessary follow-up evaluations and/or treatment based on my screening evaluation.

• I Understand that any concerns that I have about my health and healthcare are my responsibility to address with my personal healthcare provider(s).

• I Understand that I must provide required documentation regarding my health history which, upon my accession, will become part of my Service member lifecycle medical treatment record.

• I Authorize a MEPS/DODMERB contracted medical center to perform my accession medical evaluation.

• I Understand that I have the right to refuse to sign this authorization, however I also understand that failure to do so will prevent my further processing.

• I Understand that this authorization will expire four years from the date of the signature below, or sooner if written request is received by the USMEPCOM/DoDMERB

Privacy Office. I have the right to revoke this authorization in writing, except to the extent that the DoD has acted in reliance on this information.

1. APPLICANT AUTHORIZATION AND CERTIFICATION

I Certify that the information on this form is true and complete to the best of my knowledge and belief, and no person has advised me to conceal or falsify any information about my medical and mental/behavioral health history.

a. SIGNATURE b. DATE SIGNED

(YYYYMMDD)

2. PARENT OR GUARDIAN AUTHORIZATION (Signature is mandatory if applicant is a minor)

a. NAME (Last, First, Middle Initial) b. SIGNATURE c. DATE SIGNED

(YYYYMMDD)

3. RECRUITING REPRESENTATIVE CERTIFICATION: (If applicable) I certify that all applicant information above is complete and true to the best of my knowledge.

a. NAME (Last, First, Middle Initial) b. RECRUITER IDENTIFICATION NUMBER c. SIGNATURE d. DATE SIGNED

(YYYYMMDD)

PREVIOUS EDITION IS OBSOLETE.

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LAST NAME – FIRST NAME – MIDDLE INITIAL (Suffix) SOCIAL SECURITY NUMBER DoD ID NUMBER (If applicable)

SECTION III - MEDICAL HISTORY

1. Medications: any prescription or over the counter medication(s) taken regularly or as needed (list each and explain in SECTION IV)

2. Allergies: reaction to food(s), insect bites/stings, medication(s) or other substances (list each and explain in SECTION IV)

Read each of the following questions and answer by checking “YES” or “NO”. Every question must be answered. Every “YES” answer must be explained in SECTION IV. Explain each item to the best of your ability. Your medical records may be requested to clarify your medical history.

HAVE YOU EVER HAD OR DO YOU NOW HAVE: YES NO

EYES/VISION:

3. Double vision

4. Detached retina or surgery to repair a detached retina

5. Keratoconus, glaucoma, cataracts or surgery for cataracts

6. Vision correction procedure such as Lasik, PRK, or lens implant

7. Night blindness

8. Any other eye condition, injury, or surgery/procedure

EARS/HEARING:

9. Cholesteatoma

10. Ear drum perforation or tubes inserted into the ear drum(s) in the past 12 months

11. Any other ear surgery or procedure including mastoidectomy

12. Loss of balance or vertigo

13. Hearing loss or use of hearing aid(s)

NOSE, SINUSES, MOUTH, AND LARYNX:

14. Ear, nose, or throat conditions such as vocal cord dysfunction

15. Recurrent nose bleeds, chronic sinus infections, or sinus surgery

16. Absence of, or disturbance of sense of smell

17. Any surgery of the face, throat, or jaw

DENTAL: (If you wear braces/aligners, then you must submit a letter from your orthodontist stating that active orthodontic treatment will be completed before beginning active duty)

18. Braces or aligners

19. Any tooth or gum problems

LUNGS, CHEST WALL, PLEURA, AND MEDIASTINUM:

20. Asthma, asthmatic bronchitis, wheezing, shortness of breath, or other breathing problems worsened by exercise, weather, pollens, etc.

21. Prescription for an inhaler, steroids, or any other medication for breathing problem

22. Pneumonia

23. Chronic cough or frequent coughing at night

24. Collapsed lung or other lung condition(s)

25. History of chest, chest wall, or breast surgery

HEART:

26. Heart murmur or valve problem(s)

27. Palpitations, skipped/abnormal heartbeats, or pounding heart

28. Chest pain/pressure or an abnormal electrocardiogram (EKG)

29. Heart surgery

30. Any other heart condition

ABDOMEN AND GASTROINTESTINAL SYSTEM:

31. Problems of the stomach, esophagus, or intestine such as ulcer(s)

32. Frequent indigestion/heartburn, difficulty swallowing, or eosinophilic esophagitis

33. Gallbladder disease or gallstones

34. Hepatitis or jaundice (except neonatal jaundice)

35. Hernia

36. Any abdominal surgery/endoscopy such as appendectomy, bowel resection, hernia repair, or colonoscopy

37. Weight loss surgery such as gastric bypass or lap banding

38. Chronic or recurrent intestinal disease such as irritable bowel syndrome, inflammatory bowel disease, or celiac disease

39. Anorectal disease, blood from the rectum, or hemorrhoids

FEMALES ONLY:

40. First day of the last menstrual period (YYYYMMDD)

41. A change in menstrual pattern (other than pregnancy)

42. Pregnancy

43. Any abnormal PAP test

44. Endometriosis, uterine fibroid, or ovarian cyst

45. Any other gynecological disorder that required evaluation, treatment, or surgery

MALES ONLY:

46. Undescended/absent testicle(s), or testicular implant

47. Any scrotal mass, swelling, or pain

48. Prostate problems

URINARY SYSTEM:

49. Absence of, or a congenital abnormality of a kidney such as horseshoe kidney

50. Blood or protein in urine

51. Painful or difficult urination

52. Kidney stone

53. Kidney or urinary tract disease, surgery, or infection

54. Bedwetting or treatment for bedwetting in the past 12 months

SPINE AND SACROILIAC JOINTS:

55. Back or neck pain, or herniated disc

56. Abnormal curvature of any part of the spine

57. Vertebral fracture or stress injury of the spine such as spondylolysis

58. Back or neck surgery

UPPER EXTREMITIES:

59. Any pain, swelling, weakness, numbness, or stiffness of the shoulder, elbow, wrist, hand, or fingers

HAVE YOU EVER HAD OR DO YOU NOW HAVE: YES NO

UPPER EXTREMITIES: (Continued)

60. Dislocated shoulder, elbow, or wrist

LOWER EXTREMITIES:

61. Foot conditions such as plantar fasciitis, heel spur, or painful bunions

62. Knee injury resulting in ligament/cartilage tear, instability, or locking

63. Any pain, swelling, weakness, numbness, or stiffness of the hip, knee, ankle, foot, or toes

64. Dislocated hip, knee, ankle, or foot

MISCELLANEOUS CONDITIONS OF THE EXTREMITIES:

65. Bone, muscle, or joint deformity, injury, or persistent pain/swelling

66. Impaired use of arms, hands, fingers, legs, feet, or toes (any reason)

67. Joint swelling/inflammation such as arthritis, gout, or bursitis

68. Compartment syndrome, shin splints, or stress reaction/fracture

69. Any surgery of the bone or joint such as placing a screw, plate, rod, pin, prosthetic/graft or arthroscopy

70. Any use of prescribed corrective/prosthetic devices such as a brace, back support, heel lift, or orthotic inserts

VASCULAR:

71. Abnormal (high or low) blood pressure

72. Pale, blue, or numb fingers or toes with exposure to cold such as Raynaud’s phenomenon/ disease

73. Kawasaki disease

SKIN:

74. Acne that required prescription medication(s)

75. Skin rash such as atopic dermatitis, eczema, or psoriasis

76. Any other skin condition such as recurrent hives, abscesses (hidradenitis), pilonidal cyst, or cancer (melanoma)

BLOOD AND BLOOD FORMING SYSTEM:

77. Anemia such as iron deficiency, sickle cell, or thalassemia

78. Blood clot(s), a clotting disorder, or history of taking a blood thinner

79. Absence or removal of the spleen

80. Prolonged bleeding such as after an injury or dental procedure

81. Any other blood or circulation condition

SYSTEMIC:

82. Severe allergic reaction to any substance requiring emergency care

83. Tested positive for tuberculosis (skin or blood test), or lived with someone who had it

84. Immune system condition such as rheumatoid arthritis, lupus, multiple sclerosis, or AIDS

85. Sexually transmitted disease such as herpes, syphilis, gonorrhea, chlamydia, or HIV

86. Rhabdomyolysis

ENDOCRINE AND METABOLIC:

87. Thyroid conditions such as goiter or hypo/hyperthyroidism

88. Diabetes or hypoglycemia (low blood sugar)

89. Any other endocrine (hormone) condition such as growth hormone deficiency, adrenal insufficiency, or hypo/hyperparathyroidism

NEUROLOGIC:

90. Stroke, aneurysm, or bleeding in or around the brain

91. Frequent or severe headaches such as migraines, cluster, or tension

92. A head injury, concussion, or skull fracture

93. Infection of the brain or spinal cord such as abscess, meningitis, or encephalitis

94. Seizures, epilepsy, or convulsions

95. Syncope or fainting spells

96. Any other neurologic condition such as paralysis, myasthenia gravis, Tourette’s, or memory loss

SLEEP:

97. Sleep apnea

98. Sleepwalking, narcolepsy, or difficulty with sleep such as falling/staying asleep

LEARNING, PSYCHIATRIC, AND BEHAVIORAL:

99. Attention Deficit or Hyperactivity disorder (ADD/ADHD), dyslexia, autism spectrum, or other learning disorder

100. A behavioral/mental health condition such as anxiety/panic attacks, depression, adjustment disorder, PTSD, personality disorder, addiction, or drug/substance abuse including alcohol

101. Evaluation or treatment either with medication or counseling for any behavioral/mental health condition

102. Eating disorder such as anorexia or bulimia

103. Self-inflicted injury such as cutting or burning

104. Suicidal thoughts, gesture, or attempt

105. Admission to a hospital for any behavioral/mental health condition

TUMORS AND MALIGNANCIES:

106. Any cancer, malignancy, tumor, or cyst

MISCELLANEOUS:

107. Cold/heat intolerance or injury such as frostbite or heatstroke

SUPPLEMENTAL QUESTIONS:

108. Prosthetic body part or joint

109. Any medical treatment/surgery from a Hospital, Emergency Room, Surgical Center or Urgent

Care

110. Previous medical disqualification for Military Service

111. Discharge from Military Service for any reason (provide reason, date, and type of discharge)

112. Disability award or compensation for an injury or other medical condition

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LAST NAME – FIRST NAME – MIDDLE INITIAL (Suffix) SOCIAL SECURITY NUMBER DoD ID NUMBER (If applicable)

SECTION IV – APPLICANT COMMENTS

Explain all "YES" answers to questions above. Write the item number and provide details to include the following: description of the problem/condition, date of onset of the problem/condition, date of treatment, name of health care provider, clinic, center, hospital along with City and State. Comment on the current status of the problem/condition. Attach additional sheet(s) if necessary, and sign and date each additional sheet. Attach copies of all applicable medical records.

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LAST NAME – FIRST NAME – MIDDLE INITIAL (Suffix) SOCIAL SECURITY NUMBER DoD ID NUMBER (If applicable)

SECTION V – MEDICAL PROVIDER SUMMARY

The medical provider will review all applicant comments on "YES" answers, and all submitted supporting medical documentation. The provider will comment below on each "YES" answer. Attach additional sheets if necessary.

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LAST NAME – FIRST NAME – MIDDLE INITIAL (Suffix) SOCIAL SECURITY NUMBER DoD ID NUMBER (If applicable)

SECTION VI - PRESCREEN PROCESSING DETERMINATION

1.a. MEDICAL PROCESSING STATUS

PA PH RJ METR

1.b. REVIEWER INITIALS 1.c. DATE (YYYYMMDD)

KEY: PA = Processing Authorized; PH = Processing Hold; RJ = Return Justified; METR = Medical Evaluation and/or Treatment Records

2. AUTHORIZING MEDICAL PROVIDER

a. NAME (Last, First, Middle Initial) b. SIGNATURE c. DATE SIGNED (YYYYMMDD) d. NUMBER OF ADDITIONAL

SHEETS ATTACHED

SECTION VII – INTERVIEWING MEDICAL PROVIDER COMMENTS

3. INTERVIEWING MEDICAL PROVIDER

a. NAME (Last, First, Middle Initial) b. SIGNATURE c. DATE SIGNED

(YYYYMMDD)

DRAFT

SAMPLE

DD FORM 2807-2, DEC 2021

Page of CUI (when filled in) Document classification when filled in is CUI CUI (when filled in) Document classification when filled in is CUI

PREVIOUS EDITION IS OBSOLETE.

Controlled by: OUSD(P&R) CUI Category: HLTH, PRVCY

LDC: FEDCON POC: 703-695-5527

DD FORM 2807-2, DEC 2021

PREVIOUS EDITION IS OBSOLETE.

Page of CUI (when filled in) Document classification when filled in is CUI CUI (when filled in) Document classification when filled in is CUI

ACCESSIONS MEDICAL HISTORY REPORT

OMB No. 0704-0413 OMB Approval Expires:

20241031 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, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dodinformationcollections@mail.mil. 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 ADDRESS.

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C.§136, Under Secretary of Defense for Personnel and Readiness; 10 U.S.C. Subtitle A, General Military Law, Part II, Personnel (Chapter 31, Enlistments and Chapter 33, Original Appointments of Regular Officers in Grades Above Warrant Officer Grades); 10 U.S.C. 3013, Secretary of the Army; 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 8013, Secretary of the Air Force; DoD Directive (DoDD) 1145.02E, United States Military Entrance Processing Command (USMEPCOM); DoD Instruction (DoDI) 1304.02, Accession Processing Data Collection Forms; DoDI 1304.12E, DoD Military Personnel Accession Testing Programs; DoDI 1304.26, Qualification Standards for Enlistment, Appointment and Induction; DoDI 6130.03, Medical Standards for Appointment, Enlistment, or Induction in the Military Services; DoD Manual 1145.02, Military Entrance Processing Station (MEPS); USMEPCOM Regulation 680–3, Entrance Processing and Reporting System Management; and E.O. 9397 (SSN), as amended.

PURPOSE: 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): The Routine Uses are listed in the system of records notice found at: https://www.federalregister.gov/documents/2021/04/21/2021-08286/privacy-act-of-1974-system-of-records 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 confinement or $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 may be subject to prosecution under the Uniform Code of Military Justice or to administrative separation proceedings for discharge, and could receive a less than honorable discharge.

SECTION I – APPLICANT INFORMATION

5. (X each item)

a. SEX (at birth)

b. GENDER 6.a. SERVICE PROCESSING FOR (X as applicable) 6.b. COMPONENT (X as applicable)

7. PURPOSE OF EXAMINATION (X as applicable)

SECTION II - APPLICANT (OR PARENT/GUARDIAN) AUTHORIZATION STATEMENT

I Have read and understand the warning and penalties that are associated with providing a false statement.I Agree that all protected health information and personally identifiable information (PHI/PII) or data disclosed by myself or others on my behalf with my consent during the accession process is no longer protected by federal Health Insurance Portability and Accountability Act (HIPAA) Privacy Rules and may be further disseminated as needed.I Authorize release of medical records and information relating to grades, performance, individual education plans, and disciplinary proceedings. Under the Family Educational Rights and Privacy Act (FERPA), United States Military Entrance Processing Command (USMEPCOM)/Department of Defense Medical Examination Review Board (DoDMERB) is authorized to receive all of myeducation/disciplinary records for evaluation of my suitability for Military Service.I Understand that a medical examination is part of the accession evaluation, may require several visits to the Military Entrance Processing Station (MEPS), or DoDMERB contracted medical center. I may have blood work and/or other medical tests, procedures such as cerumen removal, and/or specialty consultations performed as part of my processing.I Understand that the results of the examination, tests, and consults are not performed as part of an individual healthcare treatment plan, but will be reviewed and considered as part of my accession application file. I Understand that the MEPS/DoDMERB medical staff are not my healthcare providers. If I do not receive notice of an abnormal result of a test or a consultation, I am not to assume that the result is normal. Furthermore, if any test or consultation results are abnormal, then I am responsible for obtaining those results from the MEPS/DoDMERB contracted medical center. I am also responsible for any necessary follow-up evaluations and/or treatment. If I am notified to return to the MEPS/DoDMERB contracted medical center to discuss medical results, it is my responsibility to take quick action to return to the MEPS/DoDMERB contracted medical center.I Understand that neither USMEPCOM nor DoDMERB are financially responsible for costs associated with any necessary follow-up evaluations and/or treatment based on my screening evaluation.I Understand that any concerns that I have about my health and healthcare are my responsibility to address with my personal healthcare provider(s).I Understand that I must provide required documentation regarding my health history which, upon my accession, will become part of my Service member lifecycle medical treatment record.I Authorize a MEPS/DODMERB contracted medical center to perform my accession medical evaluation. I Understand that I have the right to refuse to sign this authorization, however I also understand that failure to do so will prevent my further processing. I Understand that this authorization will expire four years from the date of the signature below, or sooner if written request is received by the USMEPCOM/DoDMERB Privacy Office. I have the right to revoke this authorization in writing, except to the extent that the DoD has acted in reliance on this information.

1. APPLICANT AUTHORIZATION AND CERTIFICATION

I Certify that the information on this form is true and complete to the best of my knowledge and belief, and no person has advised me to conceal or falsify any information about my medical and mental/behavioral health history.

2. PARENT OR GUARDIAN AUTHORIZATION (Signature is mandatory if applicant is a minor)

3. RECRUITING REPRESENTATIVE CERTIFICATION: (If applicable) I certify that all applicant information above is complete and true to the best of my knowledge.

SECTION III - MEDICAL HISTORY

Read each of the following questions and answer by checking “YES” or “NO”. Every question must be answered. Every “YES” answer must be explained in SECTION IV. Explain each item to the best of your ability. Your medical records may be requested to clarify your medical history.

HAVE YOU EVER HAD OR DO YOU NOW HAVE:

YES

NO

EYES/VISION:

3. Double vision

4. Detached retina or surgery to repair a detached retina

5. Keratoconus, glaucoma, cataracts or surgery for cataracts

6. Vision correction procedure such as Lasik, PRK, or lens implant

7. Night blindness

8. Any other eye condition, injury, or surgery/procedure

EARS/HEARING:

9. Cholesteatoma

10. Ear drum perforation or tubes inserted into the ear drum(s) in the past 12 months

11. Any other ear surgery or procedure including mastoidectomy

12. Loss of balance or vertigo

13. Hearing loss or use of hearing aid(s)

NOSE, SINUSES, MOUTH, AND LARYNX:

14. Ear, nose, or throat conditions such as vocal cord dysfunction

15. Recurrent nose bleeds, chronic sinus infections, or sinus surgery

16. Absence of, or disturbance of sense of smell

17. Any surgery of the face, throat, or jaw DENTAL: (If you wear braces/aligners, then you must submit a letter from your orthodontist stating that active orthodontic treatment will be completed before beginning active duty)

18. Braces or aligners

19. Any tooth or gum problems

LUNGS, CHEST WALL, PLEURA, AND MEDIASTINUM:

20. Asthma, asthmatic bronchitis, wheezing, shortness of breath, or other breathing problems worsened by exercise, weather, pollens, etc.

21. Prescription for an inhaler, steroids, or any other medication for breathing problem

22. Pneumonia

23. Chronic cough or frequent coughing at night

24. Collapsed lung or other lung condition(s)

25. History of chest, chest wall, or breast surgery

HEART:

26. Heart murmur or valve problem(s)

27. Palpitations, skipped/abnormal heartbeats, or pounding heart

28. Chest pain/pressure or an abnormal electrocardiogram (EKG)

29. Heart surgery

30. Any other heart condition

ABDOMEN AND GASTROINTESTINAL SYSTEM:

31. Problems of the stomach, esophagus, or intestine such as ulcer(s)

32. Frequent indigestion/heartburn, difficulty swallowing, or eosinophilic esophagitis

33. Gallbladder disease or gallstones

34. Hepatitis or jaundice (except neonatal jaundice)

35. Hernia

36. Any abdominal surgery/endoscopy such as appendectomy, bowel resection, hernia repair, or colonoscopy

37. Weight loss surgery such as gastric bypass or lap banding

38. Chronic or recurrent intestinal disease such as irritable bowel syndrome, inflammatory bowel disease, or celiac disease

39. Anorectal disease, blood from the rectum, or hemorrhoids

FEMALES ONLY:

40. First day of the last menstrual period (YYYYMMDD)

41. A change in menstrual pattern (other than pregnancy)

42. Pregnancy

43. Any abnormal PAP test

44. Endometriosis, uterine fibroid, or ovarian cyst

45. Any other gynecological disorder that required evaluation, treatment, or surgery

MALES ONLY:

46. Undescended/absent testicle(s), or testicular implant

47. Any scrotal mass, swelling, or pain

48. Prostate problems

URINARY SYSTEM:

49. Absence of, or a congenital abnormality of a kidney such as horseshoe kidney

50. Blood or protein in urine

51. Painful or difficult urination

52. Kidney stone

53. Kidney or urinary tract disease, surgery, or infection

54. Bedwetting or treatment for bedwetting in the past 12 months

SPINE AND SACROILIAC JOINTS:

55. Back or neck pain, or herniated disc

56. Abnormal curvature of any part of the spine

57. Vertebral fracture or stress injury of the spine such as spondylolysis

58. Back or neck surgery

UPPER EXTREMITIES:

59. Any pain, swelling, weakness, numbness, or stiffness of the shoulder, elbow, wrist, hand, or fingers

HAVE YOU EVER HAD OR DO YOU NOW HAVE:

YES

NO

UPPER EXTREMITIES: (Continued)

60. Dislocated shoulder, elbow, or wrist

LOWER EXTREMITIES:

61. Foot conditions such as plantar fasciitis, heel spur, or painful bunions

62. Knee injury resulting in ligament/cartilage tear, instability, or locking

63. Any pain, swelling, weakness, numbness, or stiffness of the hip, knee, ankle, foot, or toes

64. Dislocated hip, knee, ankle, or foot

MISCELLANEOUS CONDITIONS OF THE EXTREMITIES:

65. Bone, muscle, or joint deformity, injury, or persistent pain/swelling

66. Impaired use of arms, hands, fingers, legs, feet, or toes (any reason)

67. Joint swelling/inflammation such as arthritis, gout, or bursitis

68. Compartment syndrome, shin splints, or stress reaction/fracture

69. Any surgery of the bone or joint such as placing a screw, plate, rod, pin, prosthetic/graft or arthroscopy

70. Any use of prescribed corrective/prosthetic devices such as a brace, back support, heel lift, or orthotic inserts

VASCULAR:

71. Abnormal (high or low) blood pressure

72. Pale, blue, or numb fingers or toes with exposure to cold such as Raynaud’s phenomenon/disease

73. Kawasaki disease

SKIN:

74. Acne that required prescription medication(s)

75. Skin rash such as atopic dermatitis, eczema, or psoriasis

76. Any other skin condition such as recurrent hives, abscesses (hidradenitis), pilonidal cyst, or cancer (melanoma)

BLOOD AND BLOOD FORMING SYSTEM:

77. Anemia such as iron deficiency, sickle cell, or thalassemia

78. Blood clot(s), a clotting disorder, or history of taking a blood thinner

79. Absence or removal of the spleen

80. Prolonged bleeding such as after an injury or dental procedure

81. Any other blood or circulation condition

SYSTEMIC:

82. Severe allergic reaction to any substance requiring emergency care

83. Tested positive for tuberculosis (skin or blood test), or lived with someone who had it

84. Immune system condition such as rheumatoid arthritis, lupus, multiple sclerosis, or AIDS

85. Sexually transmitted disease such as herpes, syphilis, gonorrhea, chlamydia, or HIV

86. Rhabdomyolysis

ENDOCRINE AND METABOLIC:

87. Thyroid conditions such as goiter or hypo/hyperthyroidism

88. Diabetes or hypoglycemia (low blood sugar)

89. Any other endocrine (hormone) condition such as growth hormone deficiency, adrenal insufficiency, or hypo/hyperparathyroidism

NEUROLOGIC:

90. Stroke, aneurysm, or bleeding in or around the brain

91. Frequent or severe headaches such as migraines, cluster, or tension

92. A head injury, concussion, or skull fracture

93. Infection of the brain or spinal cord such as abscess, meningitis, or encephalitis

94. Seizures, epilepsy, or convulsions

95. Syncope or fainting spells

96. Any other neurologic condition such as paralysis, myasthenia gravis, Tourette’s, or memory loss

SLEEP:

97. Sleep apnea

98. Sleepwalking, narcolepsy, or difficulty with sleep such as falling/staying asleep

LEARNING, PSYCHIATRIC, AND BEHAVIORAL:

99. Attention Deficit or Hyperactivity disorder (ADD/ADHD), dyslexia, autism spectrum, or other learning disorder

100. A behavioral/mental health condition such as anxiety/panic attacks, depression, adjustment disorder, PTSD, personality disorder, addiction, or drug/substance abuse including alcohol

101. Evaluation or treatment either with medication or counseling for any behavioral/mental health condition

102. Eating disorder such as anorexia or bulimia

103. Self-inflicted injury such as cutting or burning

104. Suicidal thoughts, gesture, or attempt

105. Admission to a hospital for any behavioral/mental health condition

TUMORS AND MALIGNANCIES:

106. Any cancer, malignancy, tumor, or cyst

MISCELLANEOUS:

107. Cold/heat intolerance or injury such as frostbite or heatstroke

SUPPLEMENTAL QUESTIONS:

108. Prosthetic body part or joint

109. Any medical treatment/surgery from a Hospital, Emergency Room, Surgical Center or Urgent Care

110. Previous medical disqualification for Military Service

111. Discharge from Military Service for any reason (provide reason, date, and type of discharge)

112. Disability award or compensation for an injury or other medical condition

SECTION IV – APPLICANT COMMENTS

Explain all "YES" answers to questions above. Write the item number and provide details to include the following: description of the problem/condition, date of onset of the problem/condition, date of treatment, name of health care provider, clinic, center, hospital along with City and State. Comment on the current status of the problem/condition. Attach additional sheet(s) if necessary, and sign and date each additional sheet. Attach copies of all applicable medical records.

SECTION V – MEDICAL PROVIDER SUMMARY

The medical provider will review all applicant comments on "YES" answers, and all submitted supporting medical documentation. The provider will comment below on each "YES" answer. Attach additional sheets if necessary.

SECTION VI - PRESCREEN PROCESSING DETERMINATION

1.a. MEDICAL PROCESSING STATUS

PA

PH

RJ

METR

1.b. REVIEWER INITIALS 1.c. DATE (YYYYMMDD) KEY: PA = Processing Authorized; PH = Processing Hold; RJ = Return Justified; METR = Medical Evaluation and/or Treatment Records

2. AUTHORIZING MEDICAL PROVIDER

SECTION VII – INTERVIEWING MEDICAL PROVIDER COMMENTS

3. INTERVIEWING MEDICAL PROVIDER

9.0.0.2.20120627.2.874785 DD Form 2807-2, "ACCESSIONS MEDICAL HISTORY REPORT" Forms Management Office DoD Component