Exhibit K_DA Form 3024 - PHA.pdf

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This form must be completed electronically. Handwritten forms will not be accepted.

ANNUAL PERIODIC HEALTH ASSESSMENT

PRIVACY ACT STATEMENT

Privacy Act Statement: DD Form 3024 will collect PII that is stored in active duty and reserve servicemembers' medical and military personnel records, a system of records, and retrieved by a personal identifier. Therefore, the Privacy Act applies, and a Privacy Act Statement is required. The attached updated Privacy Act Statement should be provided to individuals prior to their completing or being asked for any of the information requested by DD Form 3024. This updated Privacy Act Statement is needed to ensure the proper SORN is fully cited, the legal authorities are updated to the proper authorities, and the citation to DoD's Blanket Routine Uses of information is removed because those uses are no longer applicable.

This statement serves to inform you of the purpose for collecting personal information as required by DD Form 3024, Annual Periodic Health Assessment, and how the information will be used.

AUTHORITIES: 10 U.S.C., Chapter Ch. 55, Medical and Dental Care; DoDI 6200.06, “Periodic Health Assessment Program” PURPOSE: To periodically assess the health and well-being of active duty and reserve military servicemembers regarding force readiness and servicemembers' suitability for deployment. Information collected will be used to assess force readiness and recommend proactive health interventions for individuals.

ROUTINE USES: Information in your records may be disclosed to personnel within the Defense Health Agency and Department of Defense for the purposes of documenting the current state of your health and well-being, assessing your suitability for deployment, and recommending proactive health intervention. Any protected health information (PHI), including mental health and substance abuse information, in your records may be used and disclosed generally as permitted by the HIPAA Rules (45 CFR Parts 160 and 164), as implemented by DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, and healthcare operations.

APPLICABLE SORN: EDHA 07, “Military Health Information System” (June 15, 2020, 85 FR 36190) https://dpcld.defense.gov/Portals/49/Documents/ Privacy/SORNs/DHA/EDHA-07.pdf

INSTRUCTIONS: You are highly encouraged to answer all questions. If you do not understand a question, please discuss the question with a health care provider. If this is your first PHA since entering the United States military (or if you don’t know if you’ve ever had a PHA) ONLY consider the PAST12 MONTHS when responding to the questions below that say “since your last PHA”.

PART A. SERVICE MEMBER QUESTIONS AND RESPONSES (TO BE COMPLETED BY THE SERVICE MEMBER)

I. SERVICE MEMBER INFORMATION AND DEMOGRAPHICS (SMI)

1. Last Name: 2. First Name: 3. Middle Initial:

4. Today’s Date (dd/mmm/yyyy) 5. Date of Birth (dd/mmm/yyyy) 6. Age:

7.Gender:

Male Female

8. Provide your 10-digit DoD ID number located on the back of your CAC.

9. Service Branch:

Air Force

Army

Navy

Marine Corps

Coast Guard

Other (List): (Skip to 16)

10. Component:

Active Duty

National Guard

Reserves

11. STATUS:

Active Duty

Traditional Guardsman

Drilling Reservist (TPU, IMA)

Active Guard Reserve (AGR) or Full-Time Support (FTS)

Individual Ready Reserve (IRR)

Inactive National Guard (ING)

Other (List):

12. Pay Grade:

E1

E2

E3

E4

E5

E6

E7

E8

E9

O1

O2

O3

O4

O5

O6

O7

O8

O9

O10

W1

W2

W3

W4

W5

Other (List):

13. Unit Name: 14. Duty Station/Location:

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15. What is your Unit Identification Code (for Army, Navy, Coast Guard), or Reporting Unit Code (for Marine Corps)?

16. Is this your first Periodic Health Assessment (PHA)? Yes No Don't Know

17. Are you enrolled in a secure messaging system with your health care provider (RelayHealth, MiCare, or Patient Portal)? (For Active Duty or Active Guard Reserve (AGR)/Full-time Support (FTS))

Yes No Don't Know

18. Current contact information (Select preferred method):

DSN Phone:

Day Time Phone:

Night Time Phone:

Email 1:

Email 2:

RelayHealth, MiCare, Patient Portal: (If applicable)

Best time to reach you:

Address: State:

ZIP Code:

19. Point of contact who can always reach you (No health or medical information will be shared with your point of contact):

Name:

Phone 1:

Phone 2:

Email:

Address:

ZIP Code:

State:

II. DEPLOYMENT INFORMATION (DEP)

1. Total number of deployments in the PAST 5 YEARS:

I have never deployed (Skip to 4)

5 or more

0 (Skip to 4)

2. Primary country of last deployment:

3. Date departed theater / deployment location: (dd/mmm/yyyy):

4. Are you going to deploy within the NEXT 120 DAYS?

Yes

No

III. OCCUPATIONAL INFORMATION (OCC)

1. What is your military occupational code (for example: MOS, AOC, AFSC, NEC, or Designator Code)?

2. Describe your typical military job duties (for example: driving a truck, fueling machinery, lifting heavy equipment, working on a computer).

3. Does your military specialty require an operational duty physical exam (e.g., flight, jump, dive, missile, submarine, personnel reliability program, Special Forces)?

No

Yes

4. Are you currently enrolled in a medical surveillance/occupational health program (or example: hearing conservation, radiation health, healthcare worker monitoring, etc.)?

Yes

No

Don't Know

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IV. MEDICAL CONDITIONS (DLMC)

1. Since your last health assessment, have you experienced any of the following health conditions, and if so what is your status?

HEALTH CONDITION NO / Does not apply to me

YES, but did NOT get medical care

YES, got medical care, but NO LONGER under treatment /follow-up

YES, and NOW under treatment / follow up

Chest pain (angina)

Congestive Heart Failure

Abnormal heart beat (arrhythmia)

High blood pressure

Asthma

Other lung problems (for example: Chronic Obstructive Pulmonary Disease (COPD), chronic bronchitis, pneumonia, emphysema)

Tuberculosis

Cancer or history of cancer

Diabetes

Change in your vision

Head injury/concussion/Traumatic Brain Injury

(TBI)

Periods of dizziness, fainting, or loss of consciousness Neurological problems (for example: stroke, seizures) Persistent or recurring noises in your head or ears (for example: ringing, buzzing, humming) Change in your hearing that impacts duty performance

High or bad cholesterol

2. Since your last PHA, have you experienced any of the following health conditions that either required medical care or impacted your duty performance (or both) and if so, what is your status?

HEALTH CONDITION NO / Does not apply to me

YES, impacted duty performance, but did NOT get medical care

YES, got medical care but NO longer under treatment / follow up

YES, and NOW under treatment / follow up

Wheezing, shortness of breath, or difficulty breathing (other than asthma)

New skin condition

Recurring muscle, joint, or low back pain

Recurring headaches/migraines

Stomach problems (for example: ulcer, reflux)

Kidney problems (for example: stones, infection)

Liver problems (for example: hepatitis, cirrhosis)

Blood problems (for example: hemophilia, sickle cell disease) Immune system problems (for example: HIV, chemotherapy, radiation)

Tooth or gum problems/pain

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3. For each condition, are you currently on any profile or limited duty (LIMDU) for that condition?

HEALTH CONDITION NO YES

Chest pain (angina)

Congestive Heart Failure

Abnormal heart beat (arrhythmia)

High blood pressure

Asthma

Wheezing, shortness of breath, or difficulty breathing (other than asthma)

Other lung problems (for example: Chronic Obstructive Pulmonary Disease (COPD), chronic bronchitis, pneumonia, emphysema)

Tuberculosis

Cancer or history of cancer

New skin condition

Diabetes

Recurring muscle, joint, or low back pain

Change in your vision

Recurring headaches/migraines

Head injury/concussion/Traumatic Brain Injury (TBI)

Periods of dizziness, fainting, or loss of consciousness

Neurological problems (for example: stroke, seizures)

Persistent or recurring noises in your head or ears (for example: ringing, buzzing, humming)

Change in your hearing that impacts duty performance

High or bad cholesterol

Stomach problems (for example: ulcer, reflux)

Kidney problems (for example: stones, infection)

Liver problems (for example: hepatitis, cirrhosis)

Blood problems (for example: hemophilia, sickle cell disease)

Immune system problems (for example: HIV, chemotherapy, radiation)

Tooth or gum problems/pain

4. Have you been based or stationed at a location where an open burn pit was used?

Yes

No

Not sure

5. Have you been exposed to toxic airborne chemicals or other airborne contaminants?

Yes

No (Skip to 8)

Not sure

6. (If “Yes” or “Not Sure” marked in 4 or 5) Are you enrolled in the Airborne Hazards and Open Burn Pit Registry?

Yes (Skip to 8)

No (Continue)

7. If you are eligible, do you elect to enroll in the Airborne Hazards and Open Burn Pit Registry?

Yes

No/Not eligible

8. Have you had any surgery since your last PHA?

Yes (Continue)

No (Skip to 10.a.)

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9. What was the condition(s) for which you had surgery and the type of surgery?

9.a. Condition: 9.a.1. Type of Surgery:

9.b. Condition: 9.b.1. Type of Surgery:

9.c. Condition: 9.c.1. Type of Surgery:

10.a. Since your last PHA, has a health care provider recommended surgery(s) that you have not had (whether you are planning to have it or not)?

Yes (Continue)

No (Skip to 11.a.)

10.b. For what condition(s) was surgery recommended? (List):

11.a. Do you currently require hearing aids, special medical supplies, CPAP, adaptive equipment, assistive technology devices, and/or other special accommodations?

Yes (Continue)

No (Skip to 12.a.)

11.b. What is your requirement(s)? (List):

12.a. Do you currently have a waiver or profile for any part of your Service’s physical fitness test? (Skip if Coast Guard or Other)

Yes (Continue)

No (Skip to 13.a.)

12.b. Which component(s) of your physical fitness test are waived/profiled? Mark all that apply.

Body Composition Analysis (BCA) / Abdominal Circumference (not Army)

Cardio Event (for example: walk, run, bike, elliptical, swim)

Crunches / Sit-Ups

(not Marine Corps) Push-Ups

(Marine Corps only) Pull-Ups or Flexed Arm Hang

Other:

13.a. Do you have any problems wearing a gas mask, ballistic helmet, body armor, and/or chemical/biological protective garments?

Yes (Continue)

No (Skip to 14.a.)

Never had to wear these items (Skip to 14.a.)

13.b. Please comment on these problems:

14.a. Have you ever been told by a health care provider that you SHOULD NOT receive a vaccine/immunization for medical reasons?

Yes (Continue)

No (Skip to 15.a.)

14.b. Which vaccines/immunizations have you been told you should NOT receive? (List):

14.c. Why? (for example: pregnancy, illness, previous reaction)

14.d. What was the reaction, if any?

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15.a. Are you CURRENTLY on a permanent profile, permanent limited duty (PLD), waiting on a MOS/Medical Retention Board (MMRB) decision, or being referred to a Medical Evaluation Board (MEB), or Physical Evaluation Board (PEB) (Army, Navy, Marine Corps, Coast Guard) or Do you CURRENTLY have an Assignment Limitation Code C (Air Force)?

Yes (Continue)

No (Skip to 16.a.)

Don't know (Skip to 16.a.)

15.b. Why are you currently on a permanent profile (Army) or an Assignment Limitation Code C (Air Force) or Permanent Limited Duty (PLD) (Navy, Marine Corps)? Why are you being referred to a Medical Evaluation Board (MEB) and/or Physical Evaluation Board (PEB) (Coast Guard)?

(Comments):

16.a. Are you on a temporary profile or temporary limited duty (LIMDU/TLD)?

Yes (Continue)

Yes, but I feel ready to be evaluated for return to full duty (Continue)

No (Skip to 17)

16.b. Why are you on a temporary profile or temporary limited duty (LIMDU/TLD)? (Comments):

17. During the PAST 2 YEARS, how many times have you been placed on a temporary profile or on temporary limited duty (LIMDU/TLD)?

V. INDIVIDUAL MEDICAL READINESS (IMR)

1. Do you have any allergies (not including seasonal or pet allergies)?

Yes (Continue)

No (Skip to 3)

Don’t Know (Skip to 3)

2. What are your allergies? Mark all that apply.

Adhesive Tape

Aspirin

Bee Stings

Codeine

Eggs

Iodine

Latex

Milk

Nickel

Nuts

Penicillin

Shellfish

Sulfa Drugs

Vaccines

Other:

3. Do you have red medical warning “dog tags,” and are they current? Some examples of what may require a red dog tag: Allergies to antibiotics and/or other medications/immunizations, diabetes, special medication requirements, sensitivity to bug bites, and sickle cell disease.

Yes, I have them and they are current

Yes, I have them, but they are not current

No, I do not have them, but I require them

No, I do not need them

4. Do you wear corrective lenses (glasses or contacts)?

Yes (Continue)

No (Skip to BEHAVIORAL HEALTH)

5. How many pairs of serviceable glasses do you have with a current prescription (verified within last 2 years)?

2 or more

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6. Do you have gas mask inserts with a current prescription (verified within last 2 years)?

Yes

No

VI. BEHAVIORAL HEALTH (MHA)

1.a. Over the PAST MONTH, which major life stressors, if any, have you experienced that are a cause of significant concern or make it difficult for you to do your work, take care of things at home, or get along with other people? Mark all that apply.

Legal Financial Spiritual Substance abuse (including alcohol) Family/Relationship

Employment Sleep Behavioral Health Other, explain:

None (Skip to 2.a)

1.b. Are you currently in treatment or getting professional help for these concerns? Yes No

2.a. In the PAST YEAR did you receive care for any mental health condition or concern such as, but not limited to, post-traumatic stress disorder (PTSD), depression, anxiety disorder, alcohol abuse, or substance abuse?

Yes No

2.b. If yes, please explain:

3. What prescription or over-the-counter medications (including herbals/supplements) for sleep, pain, combat stress, or a mental health concern are you CURRENTLY taking?

None Please list

4.a. In the past 12 months, have you gambled?

Yes (Continue) No (Skip to 5)

4.b. During the past 12 months, have you become restless, irritable, or anxious when trying to stop/cut down on gambling?

Yes No

4.c. During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled?

Yes No

4.d. During the past 12 months, did you have such financial trouble as a result of your gambling that you had to get help with living expenses from family, friends, or welfare?

Yes No

5.a. How often do you have a drink containing alcohol?

Never (Skip to 6) Monthly or less 2 - 4 times a month 2 - 3 times a week 4 or more times a week

5.b. How many drinks containing alcohol do you have on a typical day when you are drinking?

1 or 2 3 or 4 5 or 6 7 to 9 10 or more

5.c. How often do you have six or more drinks on one occasion?

Never Less than monthly Monthly Weekly Daily or almost daily

6. Have you ever had any experience that was so frightening, horrible, or upsetting that, in the PAST MONTH, you:

6.a. Have had nightmares about it or thought about it when you did not want to? Yes No

6.b. Tried hard not to think about it or went out of your way to avoid situations that remind you of it? Yes No

6.c. Were constantly on guard, watchful, or easily startled? Yes No

6.d. Felt numb or detached from others, activities, or your surroundings? Yes No

6.e. Felt guilt or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?

Yes No

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(NOTE: If three or more items on 6.a. through 6.e. are marked YES, continue to answer items 6.f. through 6.w.)

Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each question carefully and check the box for how much you have been bothered by that problem in the LAST MONTH. Please answer all items.

Not at All A Little Bit Moderately Quite a Bit Extremely

6.f. Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?

6.g. Repeated, disturbing dreams of a stressful experience from the past?

6.h. Suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it)?

6.i. Feeling very upset when something reminded you of a stressful experience from the past?

6.j. Having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of a stressful experience from the past?

6.k. Avoid thinking about or talking about a stressful experience from the past or avoid having feelings related to it?

6.l. Avoid activities or situations because they remind you of a stressful experience from the past?

6.m. Trouble remembering important parts of a stressful experience from the past?

6.n. Loss of interest in things that you used to enjoy?

6.o. Feeling distant or cut off from other people?

6.p. Feeling emotionally numb or being unable to have loving feelings for those close to you?

6.q. Feeling as if your future will somehow be cut short?

6.r. Trouble falling or staying asleep?

6.s. Feeling irritable or having angry outbursts?

6.t. Having difficulty concentrating?

6.u. Being “super alert” or watchful, on guard?

6.v. Feeling jumpy or easily startled?

6.w. How difficult have these problems (6.f. through 6.v.) made it for you to do your work, take care of things at home, or get along with other people?

Not Difficult at All

Somewhat Difficult

Very Difficult

Extremely Difficult

7. Over the LAST 2 WEEKS, how often have you been bothered by the following problems?

7.a. Little interest or pleasure in doing things

7.b. Feeling down, depressed, or hopeless

Not at All Few or Several Days

More Than Half the Days

Nearly Every Day

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(NOTE: If 7.a. or 7.b. are marked “More than half the days” or “Nearly every day,” continue to answer items 7.c. through 7.i.)

7.c. Trouble falling/staying asleep, sleep too much.

7.d. Feeling tired or having little energy.

7.e. Poor appetite or overeating.

7.f. Feeling bad about yourself – or that you are a failure or have let yourself or your family down.

7.g. Trouble concentrating on things, such as reading the newspaper or watching television

7.h. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety that you have been moving around a lot more than usual.

7.i. How difficult have these problems (7.a. through 7.h.) made it for you to do your work, take care of things at home, or get along with other people?

Not at All Few or Several Days

More Than Half the Days

Nearly Every Day

Not Difficult at All

Somewhat Difficult

Very Difficult

Extremely Difficult

8. Would you like to schedule an appointment with a health care provider to discuss any health concerns? Yes No

9. Are you interested in receiving information or assistance for a stress, emotional, or alcohol concern? Yes No

10. Are you interested in receiving assistance for a family or relationship concern? Yes No

11. Would you like to schedule a visit with a chaplain, mental health care provider, or a community support counselor?

Yes No

VII. FAMILY HISTORY AND LIFESTYLE (LIF)

1. Overall, how would you rate your health during the PAST MONTH?

Excellent Very Good Good Fair Poor

2. To the best of your knowledge, do or did any of the following blood relatives – parents, grandparents, brothers, or sisters – ever have any of the following medical problems? Mark all that apply.

Cancer or malignancy of any kind Heart-related conditions such as high blood pressure, heart attack, coronary heart disease, cardiac arrhythmia (irregular heartbeat), or sudden death Diabetes

No/Don’t Know (Skip to 6)

3. (If Cancer marked in 2) Which of the following family members has/had the history of cancer? Mark all that apply.

FAMILY HISTORY OF CANCER

Breast

Colon

Ovarian

Prostate

Other (List): ___________

Other (List): ___________

Other (List): ___________

Unknown Type of Cancer

Mother Father Any Grandmother

Any Grandfather

Any Brother

Any Sister

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4. (If heart-related conditions marked in 2) Which of the following family members has/had the history of heart-related conditions? Mark all that apply.

FAMILY HISTORY OF HEART-RELATED CONDITIONS

High Blood Pressure

Heart Attack/Coronary Artery Disease

Cardiac Arrhythmia/Irregular Heartbeat

Sudden Cardiac Death

Other (List): ___________

Other (List): ___________

Other (List): ___________

Unknown

Mother Father Any Grandmother

Any Grandfather

Any Brother

Any Sister

5. (If Diabetes marked in 2) Which of the following family members has/had the history of diabetes? Mark all that apply.

FAMILY HISTORY OF DIABETES

Type I (body is unable to produce insulin; usually develops before the age of 40)

Type II (a chronic condition that affects the way the body processes blood sugar (glucose); usually appears later in life)

Unknown

Mother Father Any Grandmother

Any Grandfather

Any Brother

Any Sister

6. I participate in moderate intensity physical activities at least 2 ½ hours, or a combination of moderate and vigorous aerobic activities, for at least 75 minutes per week.

Yes No

7. In a typical week, I do physical activities specifically designed to STRENGTHEN my muscles such as lifting weights or doing calisthenics:

Day(s) per week

8. What prescriptions or over-the-counter medications (including Tylenol, Advil, Sudafed, and/or aspirin) are you CURRENTLY taking for health problems on a ROUTINE BASIS? Do NOT include vitamins or nutritional supplements.

None

Medications

(List Medications):

9. Which of the following products, or products marketed for the following purposes, have you taken, even once, since your last PHA?

Protein Supplements/Creatine (such as products that may contain individual or blends of amino acids like leucine, arginine, glutamine, beta-alanine, BCAA, casein, soy, whey, or plant-based protein powders/shakes; or creatine alone)

Muscle Building/Testosterone Boosting Products (such as products that may contain pro-hormones, hormone boosters, hormone support, “legal steroids”, “anabolic”, deer velvet, “Andro”, anti-estrogen, estrogen blocker, DHEA, 7-Keto, IGF-1, growth hormone, Hydroxymethylbutyrate/HMB, or insulin releasing (factors)) Performance Enhancers/Pre-Workout Products (such as C4, Nitric Oxide, Mr. Hyde, Synephrine/Citrus Aurantium, bitter orange, Yohimbe/ Yohimbine, or ephedra-free stimulants)

Energy Shots, NOT including energy drinks

Weight Loss Products (such as Hydroxycut, Dexatrim, Metabolife, QuickTrim, Xenadrine, Garcinia Cambogia, green coffee bean extract, or products using marketing terms or phrases like “Ripped”, “Lipo”, “Heat”, “Cut”, or “Shred”)

Herbal or Botanical Supplements in pills, gels, and/or tablet form (such as St. John’s Wort, Ginkgo, Echinacea, Ginseng, Saw Palmetto, Black Cohosh, Curcumin, cinnamon, ginger, or clove)

Multi-Vitamins (such as Centrum or One-A-Day)

Individual Vitamins or Minerals (such as calcium, iron, selenium, vitamin C)

Omega-3 Supplements (oil such as fish, krill, cod liver, or flaxseed)

Vitamin D

Joint Care Supplements (orally consumed products to relieve/prevent joint pain or improve joint function such as glucosamine, chondroitin, or

MSM)

None of the above (Skip to 11)

NOTE: Supplements, ingredients, and terms listed in parentheses are examples only, and not meant to imply they are the only possible choices in the category.

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10. (For items marked in 9) Since your last PHA, how often did you take:

Protein Supplements/Creatine

Muscle Building Products

Performance Enhancers

Energy Shots, NOT including energy drinks

Weight Loss Products

Herbal or Botanical Supplements in pills, gels, and/or tablet form

Multi-Vitamins

Individual Vitamins or Minerals

Omega-3 Supplements

Vitamin D

Joint Care Supplements

Less Than Once a Month

Once a Month

Once a Week

Every Other Day

Once a Day

Two or More Times a Day

11. Think about the PAST 30 DAYS. How often did you eat/drink the following foods/beverages?

TYPE OF FOOD/BEVERAGE

Fruits (These include fresh, frozen, canned, dried, and 100% fruit juices. A serving is 1 cup of fruit or 1 medium size piece of fruit or ½ cup of fruit juice or ½ cup dried fruit)

Vegetables (Examples include fresh, frozen, canned, cooked, or raw: dark green vegetables (broccoli, spinach, most greens), orange vegetables (carrots, sweet potatoes, winter squash, pumpkin), legumes (dry beans, chickpeas, tofu), and others (tomatoes, cabbage, celery, cucumber, lettuce, onions, peppers, green beans, cauliflower, mushrooms, summer squash). A serving is 1 cup of raw vegetables or ½ cup of cooked vegetables)

Starchy Vegetables (These include beans (kidney, navy, pinto, black, cannellini), corn, green peas, lentils, parsnips, plantains, potatoes, pumpkins, and squash (acorn, butternut). A serving is ½ cup of cooked vegetables.)

Whole Grains (These include rye, whole wheat, or heavily seeded bread;

brown or wild rice; whole wheat pasta or crackers; oatmeal; or corn tacos. A serving is 1 slice of bread, or ½ cup of grains.)

Dairy and Calcium Containing Foods (Examples include milk (2%, 1%, ½%, skim); yogurt; cottage cheese; low-fat cheese; frozen yogurt; or other calcium fortified foods (orange juice, soy/rice milk, breakfast cereals). A serving is 8 ounces of liquid or 1 ounce of cheese.)

Fish (Examples include tuna, salmon, or other non-fried fish. A serving is 3.5 ounces or ¾ cup.)

Lean Protein (White meat from chicken/turkey)

Sugar-Sweetened Beverages (These contain caloric sweeteners and include soft drinks, fruit drinks (such as Kool-Aid, or lemonade), sweet tea, coffee/tea drinks, and sports or energy drinks (such as Gatorade or Red Bull). 1 serving is 8-12 ounces.)

Rarely or

Never

1 or 2 Servings per Week

3 to 6 Servings per Week

Serving per Day

Servings per Day

3 or More Servings per Day

12. (If Traditional Guardsman or Drilling Reservist (TPU/IMA), Individual Ready Reserve (IRR), or Inactive National Guard (ING)) Have you had a cholesterol check by a doctor, nurse, or other health care professional within the PAST 5 YEARS?

Yes

Don’t Know

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13.a. In the PAST 30 DAYS, which of the following products have you used on at least one day? Mark all that apply.

Cigarettes (If marked, SM must complete 13.d.)

Cigars, Cigarillos, or Little Cigars

Chewing Tobacco, Snuff, or Dip

Electronic Cigarettes, E-Cigarettes, or Vape Pens

Hookahs or Waterpipes

Pipes filled with tobacco (not Waterpipes)

Snus (moist tobacco powder placed under the lip)

Dissolvable Tobacco Products

Bidis (small brown cigarettes wrapped in a leaf)

Other:

None (Skip to 15)

13.b. How long have you been using tobacco products?

< 1 year 1 to 5 years 6 to 10 years 11 to 15 years > 15 years

13.c. How often do you smoke tobacco (for example cigarettes, cigars, pipes, or hookah)?

Just about every day Some days

13.d. (For individuals who smoke cigarettes) How many packs per day do you smoke?

< ½ pack/day ½ to 1 pack/day 1 ½ to 2 packs/day 2 ½ to 3 packs/day > 3 packs/day

14. Are you interested in quitting tobacco?

Yes, I would like a referral (Skip to 16) Yes, but I do not want a referral (Skip to 16) No (Skip to 16)

15. Which of the following best describes your past tobacco use?

I used tobacco in the past, but quit in (year) I have never used tobacco products

16. Are you regularly exposed to secondhand smoke, a mixture of smoke that comes from the burning end of a cigarette, cigar, or pipe, and the smoke breathed out by the smoker (housemate, carpool, work environment)?

Yes No

17. During the LAST 2 WEEKS, how many hours of sleep did you get on most days?

Less than 5 hours

5 to less than 7 hours

7 to 9 hours

More than 9 hours

18. During the LAST 2 WEEKS, have you felt impaired or unable to adequately perform due to sleepiness or poor quality sleep?

Yes No

19. Have you had any unexplained weight loss or gain since your last PHA?

Yes No

20. Sexually transmitted infections or diseases (STIs/STDs) are common. Risk factors for these include, but are not limited to (choose an answer based on your risk):

1. A new sex partner in the past 3 months

2. More than one sex partner in the last 12 months

3. Sexually active women less than 25 years of age

4. Inconsistent use of latex condoms (not using latex condoms every time)

5. Men who have sex with men

6. Sexual contact with person(s) with known STIs/STDs or known risk of STIs/STDs

7. Exchanged money or drugs for sex

8. Injection drug use

At least one of the risk factors listed applies to me

The risk factors listed do NOT apply to me

21. (For males who identify “At least one of the risk factors listed applies to me” question 20) Have you had a syphilis, chlamydia, and gonorrhea test since your last PHA?

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22. Since your last PHA, what contraceptive methods, if any, have you and your partner(s) been using to prevent pregnancy? Mark all that apply.

I am not actively taking steps to prevent pregnancy as:

I am, or my partner is, currently pregnant

My partner(s) or I intend to get pregnant in the next year

I have a same sex partner(s)

I am not sexually active

My partner(s) or I do not use any contraception

I am actively taking steps to prevent pregnancy, including:

Sterilization (for example: vasectomy, tubal sterilization, trans-cervical sterilization, hysterectomy)

Long Term - IUD (including copper or progesterone) or implant

Injectable – Every 3 months

Daily - Birth control pills

Monthly - Contraceptive patch/vaginal ring

Emergency contraception (such as Plan B)

Other contraceptive method, please describe:

With intercourse (mark all that apply):

Condoms

Withdrawal or “pulling out”

Rhythm by calendar/temperature/cervical mucus test

Cervical cap/diaphragm

23. In the last year, have you or your partner had a pregnancy scare, where you were not trying to get pregnant but were worried enough to use a home pregnancy test?

Yes No

VIII. WOMEN’S HEALTH (FEMALE SERVICE MEMBERS ONLY) (WOM)

1. Do you wish to receive contraceptive counseling?

Yes No

2. Which of the following best describes you?

I am or may be pregnant (Skip to 5)

I was pregnant or just delivered within the past 6 months (Continue)

I was pregnant or delivered 6 – 12 months ago (Continue)

I am not pregnant now, and was not pregnant or delivered in the past 12 months (Continue)

3. Have you had a total hysterectomy (uterus and cervix removed)?

Yes (Skip to 7) No (Continue)

4. Are you postmenopausal and no longer experiencing menstrual cycles?

Yes (Skip to 7) No (Continue)

5. Are you currently taking folic acid or a vitamin containing folic acid?

Yes

No

Don’t Know

6. Do you have heavy and/or irregular menstrual cycles/pain or premenstrual syndrome (PMS)?

Yes, but I am in treatment and having no problems

Yes, and I am having ongoing issues

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7. Do you have recurrent urinary tract infections (more than 3 in the past 12 months)?

Yes, but I am in treatment and having no problems

Yes, and I am having ongoing issues

No

8. (If Question 3 is “No” or “Blank”) Have you had a Pap test (cervical cancer screening) within the PAST 3 YEARS?

Yes

No

Don’t Know

9. Have you ever had an abnormal Pap Test?

Yes (continue)

No (skip to 11)

Don’t Know (continue)

10. Have you ever had a colposcopy (test to better look at cervix), excisional procedure (known as LEEP or Cold Knife Cone), or cryotherapy (freezing) on your cervix?

Yes

No

Don’t Know

11. (If age 50 or older) Have you had a mammogram within the PAST 24 MONTHS?

Yes

No

12. (If pregnant or may be pregnant (Question 2) and/or “At least one of the risk factors listed applies to me” (Question LIF20)) Have you had a syphilis, chlamydia and gonorrhea test since your last PHA?

Yes

No

13. Do you have a history of gestational diabetes?

Yes

No

IX. RESERVE COMPONENT (TRADITIONAL GUARDSMEN, DRILLING RESERVISTS (TPU,IMA), INDIVIDUAL READY RESERVE (IRR), INACTIVE NATIONAL GUARD (ING) ONLY, NOT AGR/FTS) (RES)

(Questions are for Traditional Guardsmen and Drilling Reservists, Individual Ready Reserve, and Inactive National Guard.

All others skip to OTHER MEDICAL)

1. Do you have an injury, illness, or disease which was incurred or aggravated while in a duty status since your last PHA?

Yes (Continue) No (Skip to 4)

2. Have you completed or are you pending a Line of Duty (LOD) for that injury, illness, or disease to receive healthcare within the Military Health System (MTF or TRICARE referral from Defense Health Agency Great Lakes) or the VA?

Yes, I have an initiated LOD or it is pending

Yes, I have a completed LOD

No

3. What is your injury, illness, or disease? When did it occur?

Injury/Illness/Disease (1): Date (mmm/yyyy):

Injury/Illness/Disease (2): Date (mmm/yyyy):

Injury/Illness/Disease (3): Date (mmm/yyyy):

4. Are you currently covered under a health insurance policy? Mark all that apply.

Yes -- TRICARE Yes -- Other health insurance No

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5.a. Do you have any current physical or mental health limitations related to a Workers’ Compensation claim (regardless of whether the claim was approved)?

Yes (if yes, list limitations)

No, I have never applied for Worker’s Compensation

No, I applied for Worker’s Compensation, but have no limitations

5.b. List Limitations:

6. Have you applied for, or have you received a VA disability rating?

No (Skip to OTHER MEDICAL)

Yes, I received a VA disability rating (Continue)

Yes, my application is pending (Skip to 9)

Yes, I applied, but my claim was denied (Skip to 9)

7. What is your total disability rating (%)?

8. What is the approximate date you received your disability rating (mmm/yyyy)?

9. What type of injury(s) or medical condition(s) is the basis of your VA disability claim(s)?

10. List any physical or mental health limitations you have related to your VA disability injury(s)/condition(s):

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X. OTHER MEDICAL (OTH)

1. (PAIN SCALE) Rate the amount of pain you have had, on average, over the PAST 24 HOURS.

0 = No pain (Skip to 3)

1 = Hardly notice pain (Continue)

2 = Notice pain, does not interfere with activities (Continue)

3 = Sometimes distracts me (Continue)

4 = Distracts me, can do usual activities (Continue)

5 = Interrupts some activities (Continue)

6 = Hard to ignore, avoid usual activities (Continue)

7 = Focus of attention, prevents doing daily activities (Continue)

8 = Awful, hard to do anything (Continue)

9 = Can’t bear the pain, unable to do anything (Continue)

10 = As bad as it could be, nothing else matters (Continue)

2. Are you receiving treatment for pain?

Yes No

3. Since your last PHA, have you received care or treatment for any medical and/or mental health condition(s) from a CIVILIAN or NON-MILITARY facility? This includes privately paid elective surgeries.

Yes (Continue) No (Skip to 5)

4. List the condition(s) treated and where the care was provided.

(List Conditions): (Where care was provided):

5. I acknowledge I am responsible to report medical (including mental health) and health issues that may affect my readiness to deploy or fitness to continue serving in an active status in accordance with Department of Defense Instruction 6025.19, Individual Medical Readiness. As a condition of continued participation in military service, I must report significant health information to my chain of command. In addition, I will authorize and facilitate disclosures of all health information by any non-DoD health care provider(s) to the Military Health System (MHS) and/or to my respective Reserve Component.

I Acknowledge

6. Are you concerned about any other health condition(s) or health risk exposures not already addressed?

Yes, please explain:

None

7. Would you like to schedule an appointment with a health care provider to discuss any health concerns?

Yes No

XI. SEPARATION AND RETIREMENT (SEP)

1. Are you planning to separate or retire within the next year from Active Duty or Reserve Duty (activated for greater than 30 continuous days) or do you intend to file a claim for disability compensation with the Veterans Benefits Administration?

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PART B. RECORD REVIEW AND RECOMMENDATIONS (RECORD REVIEWER ONLY)

I. RECORD REVIEWER INFORMATION

1. Last Name: 2. First Name: 3. Middle Name:

4. Service Branch/Affiliation:

Air Force

Army

Navy

Marine Corps

Coast Guard

U.S Public Health Service

Other (List):

5. Status:

Active Duty

Traditional Guardsman

Reservist

Active Guard Reserve or Full-time Support

Air Reserve Technician

Civilian Government Employee

Contractor

Other (List):

6. Title:

Physician (MD, DO)

Physician Assistant (PA)

Nurse Practitioner (NP)

Advance Practice Nurse (Clinical Nurse Specialist)

Registered Nurse (BSN, ADN, Diploma Graduate)

Licensed Vocational Nurse (LVN, LPN)

Independent Duty Medical Technician

Independent Duty Corpsman

Independent Duty Health Services Technician

Special Forces Medical Sergeant

Medic/Corpsman/Medical Technician

Public Health Technician

Health Services Technician

Medical Clerk

Other (List):

7. Email: 8. Facility: 9. Unit:

10. Address: 11. State: 12. ZIP Code:

13. Phone (Commercial):

14. Date Record Review Initiated (dd/mmm/yyyy):

II. MEDICAL SCREENING

1. Date of Service member’s most recent PHA (dd/mmm/yyyy): No PHA Documented

2. Service member’s most recently documented height: Feet: Inches: Date (dd/mmm/yyyy): No Height Documented

3. Service member’s most recently documented weight: Pounds: Date (dd/mmm/yyyy): No Weight Documented

4. What is the Service member’s most recently documented blood pressure reading?

Date (dd/mmm/yyyy): Systolic/Diastolic: No Blood Pressure Documented

5. Does the Service member have a history of abnormal blood pressure since their last PHA? Yes No

6. Does the Service member have a laboratory test of sickle cell trait documented in their permanent medical record? Yes No

7. What is the date of the Service member’s most recently documented cholesterol test?

Date (dd/mmm/yyyy): No Cholesterol Test Documented

8. (For individuals >50 years of age) What is the date of the Service member’s most recently documented colon cancer screening?

Date (dd/mmm/yyyy): No Colon Cancer Screening Documented

9. List of Service member’s active medications listed in their permanent medical record:

(List): No Active Medications Documented

10. Is there a discrepancy between the active medication record review and the Service member’s self-reported list of medications?

(Medications from MHA3 and LIF8)

Yes No If “Yes,” list discrepancies:

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11. List documented significant care the Service member has received since their last PHA from a provider OUTSIDE the Military Health System (for example a civilian or non-military facility). This includes privately paid elective surgeries.

List: No Outside Care Documented

12. Is there a discrepancy between the Service member’s list of OUTSIDE care (from OTH3), and the OUTSIDE care found in the record (see 11)?

Yes No If “Yes,” list discrepancies:

13. List documented significant care the Service member has received since their last PHA from a provider INSIDE the Military Health System.

List: No Inside Care Documented

14. (If Service member reported having surgery since their last PHA in DLMC4) Is there documentation in the record for each surgery listed below?

CONDITION TYPE OF SURGERY

(List 1 from DLMC5): (List 1 from DLMC5):

(List 2 from DLMC5): (List 2 from DLMC5):

(List 3 from DLMC5): (List 3 from DLMC5):

YES NO Record Unavailable

15. (If Service member answered “Yes” in DLMC10.a.) Confirm that vaccine exemptions are listed in the medical record and that Service member has documented exemption(s) in the appropriate system of record (AHLTA, ASIMS, MEDPROS, MRRS, etc.) for each vaccine listed (from DMLC10.b.).

Confirmed All Not All Confirmed Comments:

16. (If Service member reported allergies in IMR1) Review available medical documentation and compare with Service member responses.

Document any discrepancies.

Service member’s reported allergies (from IMR2):

Discrepancies with Record

Not All Confirmed

Comments (If “Discrepancies with Record”):

III. OCCUPATION-SPECIFIC EXAMINATIONS

1. (If the Service member indicated they are required to have a special operational duty physical exam in OCC3) When was the Service member’s most recently documented special operational duty physical exam (e.g., flight, jump, dive, missile, submarine, reliability program, Special Forces, etc.)?

Date (dd/mmm/yyyy): No Documented Exam Record Unavailable

2. (If the Service member indicated they are enrolled in a medical surveillance/occupational health program in OCC4) When was the Service member’s most recently documented evaluation (for example: hearing conservation, radiation health, healthcare worker/hospital employee monitoring, etc.)?

Date (dd/mmm/yyyy): No Documented Evaluation Record Unavailable

IV. FAMILY HISTORY AND LIFESTYLE

1. Does the DD 2766 reflect the Service member’s reported family history (from LIF2-5)?

Yes, DD2766 reflects correct family history

No, DD2766 needs to be updated If “No” describe needed update(s):

2. (For males who identify “At least one of the risk factors listed applies to me” in (LIF20)) Is there a record of the Service member receiving a syphilis, chlamydia and gonorrhea test since their last PHA?

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V. WOMEN’S HEALTH

1. (If Service member reported she is or may be pregnant OR delivered in past 6 months in WOM2) The Service member indicated a possible pregnancy, pregnancy, or recent delivery. Does the Service member have an appropriate profile and/or waiver in accordance with Service policy?

Not Applicable, pregnancy not yet confirmed (Skip to 3)

No, does not have a profile/waiver (Skip to 3)

Yes, has a profile/waiver (Continue)

2. Review the appropriate health records associated with this pregnancy and summarize, noting if the Service member has been evaluated for any occupational health concerns.

Notes:

3. (If Service member reported she has not had a total hysterectomy in WOM3) What is the date and result of the Service member’s most recent Pap test?

Date (dd/mmm/yyyy): Normal Abnormal No Documented Pap Test

4. (If Service member reported she had an abnormal PAP test in WOM9 or had a colposcopy, excisional procedure, or cryotherapy on her cervix in WOM10) Review the appropriate health records associated with history of abnormal Pap, colposcopy, excisional procedure, or cryotherapy, and summarize next required follow up.

Notes:

5. (If Service member is age 50 or greater) What is the date of the Service member’s most recently documented mammogram?

Date (dd/mmm/yyyy): No Documented Mammogram

6. (If Service member is or may be pregnant (WOM2), and/or is a female who identifies “At least one of the risk factors listed applies to me” (LIF20)) Is there a record of the Service member receiving a syphilis, chlamydia, and gonorrhea test since her last PHA?

Yes No

VI. DEPLOYMENT-RELATED HEALTH ASSESSMENTS

1. (If DEP3 date is within past 3 years) Based on your check of records, does the Service member have any due or overdue deployment health assessments which need to be completed with this PHA?

Yes No

2. (If DEP4 marked “YES”) Service member indicated a scheduled deployment in the next 120 days. Has the Service member completed the Pre-Deployment Health Assessment (DD Form 2795) for their upcoming deployment (if required)?

Yes No

VII. INDIVIDUAL MEDICAL READINESS

Deployment-Limiting Medical & Dental Conditions

1. Is the Service member currently on a profile, limited duty (LIMDU), temporary limited duty (TLD), waiting on a MOS/Medical Retention Board (MMRB) decision, or being referred to a medical evaluation board (MEB) or physical evaluation board? (PEB), (if Army, Navy, Marine Corps, Coast Guard), or Is the Service member currently on an Assignment Limitation Code C (for Air Force)?

Yes No

2. (If answered “Yes” or “Yes, but” to DLMC12.a.) How many months in the past year has the Service member been on temporary duty / temporary profile / temporary limited duty (LIMDU/TLD) / MEDHOLD / NMA / MRR / LOD status?

Number of Months: Date Temporary Situation Expires (dd/mmm/yyyy): No Record of Temporary Situation

Dental Assessment

3. When was the Service member’s most recently documented dental exam?

Date (dd/mmm/yyyy): Classification: 1 2 3 4 No Classification Code Listed No Dental Exam Documented

Immunizations

4. Is the Service member current on all required immunizations in the immunization tracking system?

Yes No If “No” List Overdue Immunization(s):

Individual Medical Equipment

5. (If Service member reported wearing corrective lenses in IMR4) Is the Service member current with Service-specific requirements for glasses and gas mask inserts?

Yes, Service member is current No, Service member needs: (List):

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Medical Readiness & Laboratory Studies

6. Does the Service member have the following laboratory tests documented in their permanent medical record?

TEST TYPE YES NO

Human Immunodeficiency Virus (HIV) test within the PAST 24 MONTHS

G6PD results on file

Blood type and Rh on file

DNA test on file

VIII. RESERVE COMPONENT (GUARD AND RESERVE ONLY)

1. (If Service member indicated they have a VA disability rating in RES6) What is the Service member’s VA disability rating?

Percent VA Disability Rating (%): No Documented VA Disability Rating (%)

IX. ADDITIONAL RECORD REVIEWER COMMENTS

1. If the record review indicates the potential need for provider notification or referral, mark below. Consult with a provider as necessary and annotate action(s) taken under “comments” in Question 2. Mark all that apply.

Provider Notified Command Notified Notification is NOT required

2. Provide any additional comments about this record review that need to be forwarded to the Health Care Professional completing PART C (Provider Review, Interview, Assessment, and Recommendations) of this form.

Comments: No additional comments

X. RECORD REVIEWER DIGITAL SIGNATURE AND COMPLETION DATE

Record Reviewer Digital Signature: Date Record Review Completed (dd/mmm/yyyy):

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PART C. HEALTH CARE PROVIDER (HCP ONLY)

(Provider Review, Interview, Assessment and Recommendations)

1. Indicate which assessment(s) you are completing:

Both PHA & MHA (Continue to Section I)

PHA ONLY

(Skip to Section III)

MHA ONLY

(Continue to Section I)

I. MENTAL HEALTH ASSESSMENT (MHA) PROVIDER INFORMATION

1. Last Name: 2. First Name: 3. Middle Name:

4. Service Branch:

Air Force

Army

Navy

Marine Corps

Coast Guard

U.S Public Health Service

Other (e.g., RHRP contractor)

5. Status:

Active Duty

Traditional Guardsman

Reservist

Active Guard Reserve or Full-time Support

Civilian Government Employee

Civilian Contractor

Other (List):

6. Select the appropriate title.

Physician (MD, DO)

Nurse Practitioner (NP)

Physician Assistant (PA)

Advance Practice Nurse (Clinical Nurse Specialist)

Independent Duty Corpsman

Independent Duty Health Services Technician

Independent Duty Medical Technician

Special Forces Medical Sergeant

Clinical Psychologist

Other Licensed Mental Health Professional

7. Email: 8. Facility: 9. Unit:

10. Address: 11. State: 12. ZIP Code:

13. Phone (Commercial):

14. Date MHA Provider Review Initiated (dd/mmm/yyyy):

II. MENTAL HEALTH ASSESSMENT (Corresponds with Service Member Section VI. Behavioral Health (MHA))

Service member reports most recent deployment was to/is to (Country): , and has deployed: times before in the past five years.

1. Major life stressor as reported on Service member (MHA1.a.).

a. Did Service member mark they have a concern or a difficulty with a major life stressor?

Yes No (Skip to 2) Not answered by Service member If “Yes” list Service members concern(s):

b. If “Yes,” ask additional questions to determine level of problem:

c. Consider need for referral. Referral indicated?

Yes (complete blocks 9 and 10) No: Already under care

Already has a referral

No significant impairment

Other reason (explain):

2. Address concerns as reported in Service member questions (MHA2 and MHA3).

Service member question Not answered

Yes response Service member’s response: Provider comments (if indicated):

History of mental health care

Medications

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3. Alcohol use as reported in Service member question (MHA5).

a. Service member’s AUDIT-C screening score was: If score between 0-4 (men), or 0-3 (women) nothing required, go to block 4.

Not answered by Service member

Number of drinks per week: Maximum number of drinks per occasion:

Based on the AUDIT-C score and assessment of alcohol use, follow the guidance below:

Alcohol Use Intervention Matrix

Assess Alcohol Use AUDIT-C Score Men (5 – 7) Women (4 - 7)

AUDIT-C Score Men and Women( > 8)

Alcohol use WITHIN recommended limits:

Men: ≤ 14 drinks per week OR ≤ 4 drinks on any occasion

Women: ≤ 7 drinks per week OR ≤ 3 drinks on any occasion

Alcohol use EXCEEDS recommended limits:

Men: > 14 drinks per week OR > 4 drinks on any occasion

Women: > 7 drinks per week OR > 3 drinks on any occasion

Advise patient to stay below recommended limits conduct BRIEF counseling*

AND

consider referral for further evaluation

Refer if indicated for further evaluation

AND

Conduct BRIEF counseling*

* BRIEF counseling: Bring attention to elevated level of drinking; Recommend limiting use or abstaining; Inform about the effects of alcohol on health;

Explore and help/support in choosing a drinking goal; Follow-up referral for specialty treatment, if indicated.

b. Referral indicated for evaluation: Yes (Complete blocks 9 and 10) No (Provide education/awareness as needed)

State reason if AUDIT-C Score was 8+:

Already under care

Already has referral

No significant impairment

Other reason (explain):

4. PTSD screening as reported in Service member question (MHA6).

a. Did Service member mark yes on three or more of questions (MHA6.a. through MHA6.e.)?

Yes No (go to block 5) Not answered by Service member

b. If yes, Service members responses to questions (MHA6.f. through MHA6.v.) resulted in a PCL-C score of (X), and the Service member’s response to level of impairment…