RHRP-II Attachment 19 - USAFR PHA Form - 2808.pdf
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- Attached to
- Reserve Health Readiness Program (RHRP) II Federal contract opportunity
- Solicitation number
- HT0011-12-R-0009
- Issued by
- Defense Health Agency
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HT0011-12-R-0009 Attachment 19 - USAFR PHA Form
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REPORT OF MEDICAL EXAMINATION
1. DATE OF EXAMINATION
(YYYYMMDD)
3. LAST NAME - FIRST NAME - MIDDLE NAME
(SUFFIX)
2. SOCIAL SECURITY NUMBER
6. GRADE
4. HOME ADDRESS (Street, Apartment Number, City, State and ZIP Code) 5. HOME TELEPHONE
NUMBER
(Include Area Code)
7. DATE OF BIRTH
(YYYYMMDD)
8. AGE 9. SEX
Female
Male
10.a. RACIAL CATEGORY (X one or more)
White
Black or African American
American Indian or Alaska Native
12. AGENCY (Non-Service Members Only) 13. ORGANIZATION UNIT AND UIC/CODE11. TOTAL YEARS GOVERNMENT
SERVICE
a. MILITARY b. CIVILIAN
16. NAME OF EXAMINING LOCATION, AND ADDRESS
(Include ZIP Code)
14.a. RATING OR SPECIALTY (Aviators Only) b. TOTAL FLYING TIME
44. NOTES: (Describe every abnormality in detail. Enter pertinent item number before each comment. Continue in item 73 and use additional sheets if necessary.)
DoD exception to SF 88 approved by ICMR, August 3, 2000.
PREVIOUS EDITION IS OBSOLETE.
Asian
c. LAST SIX MONTHS
15.a. SERVICE
Army
Navy
Marine Corps
Air Force
Active Duty
Reserve
National Guard
c. PURPOSE OF EXAMINATION
Enlistment
Commission
Retention
Separation
Medical Board
Retirement
U.S. Service Academy
ROTC Scholarship Program
Other
Nor-mal
Ab-norm NE
17. Head, face, neck, and scalp
18. Nose
19. Sinuses
20. Mouth and throat
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)
21. Ears - General (Int. and ext. canals/Auditory acuity under item 71)
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)
42. Endocrine
43. DENTAL DEFECTS AND DISEASE
35. FEET (Continued) (Circle category)
Normal Arch
Pes Cavus
Pes Planus
Mild
Moderate
Severe
Asymptomatic
Symptomatic
DD FORM 2808, OCT 2005 Page 1 of 3 Pages
CLINICAL EVALUATION (Check each item in appropriate column. Enter "NE" if not evaluated.)
b. COMPONENT Coast Guard
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.
Class
Acceptable
Not Acceptable
(Please explain. Use dental form if completed by dentist. If dental examination not done by dental officer, explain in Item 44.)
Native Hawaiian or Other Pacific Islander Hispanic/Latino
Not Hispanic/ Latino
b. ETHNIC CATEGORY
FormFlow/Adobe Professional 6.0
MEASUREMENTS AND OTHER FINDINGS
53. HEIGHT 54. WEIGHT 56. TEMPERATURE
58. BLOOD PRESSURE
a. 1ST
SYS.
DIAS.
b. 2ND
SYS.
DIAS.
c. 3RD
SYS.
DIAS.
57. PULSE
61. DISTANT VISION
Right 20/
Left 20/
Corr. to 20/
Corr. to 20/
62. REFRACTION BY AUTOREFRACTION OR MANIFEST
By
By
S.
S.
CX
CX
63. NEAR VISION
Right 20/
Left 20/
Corr. to 20/
Corr. to 20/ by by
64. HETEROPHORIA (Specify distance)
ES EX R.H. L.H. Prism div. Prism Conv
CT
NPR PD
65. ACCOMMODATION
Right Left
66. COLOR VISION (Test used and result) 67. DEPTH PERCEPTION (Test used and score) AFVT
PIP /14
68. FIELD OF VISION
59. RED/GREEN (Army Only)
71a. AUDIOMETER
Right
Left
500 1000 2000 3000 4000 6000
73. NOTES (Continued) AND SIGNIFICANT OR INTERVAL HISTORY (Use additional sheets if necessary.)
60. OTHER VISION TEST
Uncorrected Corrected
69. NIGHT VISION (Test used and score) 70. INTRAOCULAR TENSION
O.D.
72a. READING ALOUD
TEST
DD FORM 2808, OCT 2005 Page 2 of 3 Pages
LAST NAME - FIRST NAME - MIDDLE NAME (SUFFIX) SOCIAL SECURITY NUMBER
HZ
Unit Serial Number
Date Calibrated (YYYYMMDD)
a. Albumin
b. Sugar
LABORATORY FINDINGS
TESTS
46. URINE HCG 47. H/H
RESULTS
49. HIV
50. DRUGS
51. ALCOHOL
52. OTHER
a. PAP SMEAR b.
c.
HIV SPECIMEN ID LABEL DRUG TEST SPECIMEN ID LABEL
55. MIN WGT - MAX WGT
O.S.
SAT UNSAT
45. URINALYSIS
MAX BF %
lbs.
Right
Left
500 1000 2000 3000 4000 6000HZ
71b. Unit Serial Number
Date Calibrated (YYYYMMDD)
48. BLOOD TYPE
72b. VALSALVA
SAT UNSAT
b. PHYSICAL PROFILE
P U L H E S X
74.a. EXAMINEE/APPLICANT (check one)
IS QUALIFIED FOR SERVICE
IS NOT QUALIFIED FOR SERVICE
76. SIGNIFICANT OR DISQUALIFYING DEFECTS
DD FORM 2808, OCT 2005 Page 3 of 3 Pages
75. I have been advised of my disqualifying condition.
a. SIGNATURE OF EXAMINEE b. DATE (YYYYMMDD)
LAST NAME - FIRST NAME - MIDDLE NAME (SUFFIX) SOCIAL SECURITY NUMBER
PROFILER INITIALS DATE (YYYYMMDD)
ITEM
NO. MEDICAL CONDITION/DIAGNOSIS ICD
CODE
PROFILE
SERIAL
RBJ DATE
(YYYYMMDD) SERVICE DATE (YYYYMMDD)
EXAMINER
INITIALS
WAIVER RECEIVED
80. MEDICAL INSPECTION DATE HT WT %BF HCG QUAL DISQ PHYSICIAN'S SIGNATUREMAX WT
81.a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER b. SIGNATURE
83.a. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN (Indicate which) b. SIGNATURE
84.a. TYPED OR PRINTED NAME OF REVIEWING OFFICER/APPROVING AUTHORITY b. SIGNATURE
87. NUMBER OF
ATTACHED SHEETS
85. This examination has been administratively reviewed for completeness and accuracy.
a. SIGNATURE c. DATE (YYYYMMDD)b. GRADE
86. WAIVER GRANTED (If yes, date and by whom)
YES
NO
82.a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER b. SIGNATURE
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 DATE (YYYYMMDD) INITIAL WKID ST DATE (YYYYMMDD) INITIAL
QUALI-
FIED
DIS-
QUALI-
FIED
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