Attachment 21c DD2766 Adult Prevention and Chronic Care Flowsheet.pdf

DoD Form PDF 351 KB Posted

Attached to
Occupational Health Services
Solicitation number
SP4702-11-R-0001
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Attachment 21c

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3 government files on GovTribe name DD Form 2766. Different revisions are separate documents; copies of this exact file point search engines to its first posting.

File Revision Posted Attached to
dd2766.pdf Revision not stated Medical Surveillance
DD_2766.pdf Revision not stated Medical Surviellance Examination Services

Who attaches DD Form 2766

Agency Files
Department of the Air Force Reserve Command 2
Defense Logistics Agency Land and Maritime 1

Other files

File Type Posted
SP4702-11-R-0001 Amend 0002 pg 1_Page_1.jpg JPG image
SP4702-11-R-0001 Amendment 0002 pgs 2-11.pdf PDF
Amend 0001 11-R-0001 Pg1.pdf PDF
Attachment 21d OF178 Example for Deployment.pdf PDF
Attachment 26 Health Promotions Screenings.doc DOC document
Attachment 7 DLA inj.docx DOCX document
Amendment 0001 Replacement pages.pdf PDF
Amendment 0001 SP4702-11-R-0001.pdf PDF
Attachment 18 Radiation monitoring.pdf PDF
Attachment 33 Foreign Travel Vacination Review.pdf PDF
Attachment 2 Govt Property.xls XLS spreadsheet
Attachment 31 WD05-2417(Rev.14) Amend 0001.pdf PDF
Attachment 6 DFAS inj.docx DOCX document
Attachment 8 DISA inj.docx DOCX document
Attachment 21d OF 178 Example for Pre-employment Medical Surveillance.pdf PDF
Attachment 7 DLA inj.docm DOCM document
Attachment 8 DISA inj.docm DOCM document
Attachment 25 DA Form 5006-R Authorization for Disclosure of Information.pdf PDF
Attachment 23 DoDI 6200.03 Public Health Emergency Mgmt within DoD.pdf PDF
Attachment 6 DFAS inj.docm DOCM document
Attachment 30.xlsx XLSX spreadsheet
Attachment 5 Refusal of Medical Services.pdf PDF
Attachment 14 CA16.pdf PDF
Attachment 13 CLIN sheet .docx DOCX document
Attachment 19 Mod 10 to USCENTCOM Indiv Protectection Indiv Unit Deployment.pdf PDF
Attachment 4 Potential exposure to BBP.pdf PDF
Attachment 21a DD2795 Pre Deployment Health Assessment.pdf PDF
Attachment 11 CA1.pdf PDF
Attachment 20 PPG-Tab A To accompany Mod 10.pdf PDF
Attachment 29.xls XLS spreadsheet
Attachment 21h BMI for Deploying DoD Civilians to SWA.pdf PDF
Attachment 31-DOL 05-2417 dtd 9.14.10.pdf PDF
List of Attachments.docx DOCX document
Attachment 10 CA20.pdf PDF
Attachment 21g OSHA Respirator medical Evaluation Questionnaire.pdf PDF
Attachment 28 Privacy Act Statement - Health Care Records.pdf PDF
Attachment 16 Equipment Supplement.doc DOC document
Attachment 22 CENTCOM Medical waiver Request Documentation.pdf PDF
Attachment 1 Security Safety Fire.doc DOC document
Attachment 24 Government Records.doc DOC document
Attachment 21b DD2813 DoD Active Reserve Forces Dental Examination.pdf PDF
Attachment 21f DD 2808 Report of Medical Examination.pdf PDF
Attachment 17 Police Officers.pdf PDF
Attachment 9 Medical Officer Report.pdf PDF
Attachment 27 DSCC 2278-AED Class Registration Form.pdf PDF
Attachment 21i DD2807-1 Report of Medical History.pdf PDF
SF 1449 PAGE 1.pdf PDF
Attachment 3 Weather Emergencies.doc DOC document
Attachment 21e DD FORM 771 EYEWEAR PRESCRIPTION.pdf PDF
Attachment 21d SF78 Certificate of Medical Examination.pdf PDF
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ADULT PREVENTION AND CHRONIC CARE FLOWSHEET

(This form is subject to the Privacy Act of 1974 – Use DD form 2005)

1. ALLERGIES

a. MEDICATION ALLERGIES b. OTHER ALLERGIES

2. CHRONIC ILLNESS 3. MEDICATIONS

4. HOSPITALIZATIONS/SURGERIES

5. COUNSELING

F FITNESS a. DATE D DENTAL b. AGE

I INJURY PREVENTION

N NUTRITION/FOLATE

C CANCER PREVENTION

c. TOPIC

S SAFE SEX d. DATE FP FAMILY PLANNING e. AGE

RX PRESENT MEDICATIONS

MH MENTAL HEALTH/STRESS/SUICIDE/

OCCUPATIONAL STRESS

f. TOPIC

H HORMONE/CALCIUM REPLACEMENT g. DATE To TOBACCO h. AGE

A ALCOHOL/SUBSTANCE ABUSE

t TRAVEL o OCCUPATIONAL EXPOSURE

(HEARING THRESHOLD CHANGES/

CUMULATIVE TRAUMA DISORDER)

i. TOPIC

j. DATE

k. AGE

l. TOPIC

ADVANCE DIRECTIVES: DATE FILED

PATIENT’S IDENTIFICATION (Use this space for mechanical imprint)

SUPPLIED (Navy) 2766-0102-LF-984-8400, pkg-100

RECORDS MAINTAINED AT:

PATIENT’S NAME

LAST FIRST M.I.

SEX

RELATIONSHIP TO SPONSOR STATUS RANK/GRADE

SPONSOR’S NAME (Last, First, Middle Initial) DEPT/SERVICE

ORGANIZATION SSN/ID NUMBER DATE OF BIRTH

DD FORM 2766, (Rev. 01-00) PAGE 1 of 4 PAGES

6. FAMILY HISTORY M = Mother, F = Father, S = Sibling, MGM = Maternal Grandmother, MGF – Maternal Grandfather, PGM = Paternal Grandmother, PGF = Paternal Grandfather)

a. CANCER (Specify)

b. CARDIOVASCULAR DISEASE (Specify)

c. DIABETES (Specify)

d. MENTAL ILLNESS/CHEMICAL DEPENDENCY (Specify)

7. SCREENING EXAMS (* = Actual Result, ** = Tricare Benefit, N = Normal, X = Abnormal, E = Done Elsewhere, R = Refused, NA = Not Indicated) (● = Next Due)

c. YEAR a. TEST b. FREQUENCY

d. AGE

e. DATES (1) CLINICAL DISEASE

PREV EVAL/PHA (HEAR)

ANNUAL

*(2) WEIGHT ANNUAL FOR ACTIVE DUTY

*(3) HEIGHT ANNUAL FOR ACTIVE DUTY

*(4) BLOOD PRESSURE ONCE q 2 YRS FOR BP <

130/85, ANNUAL IF GREATER

*(5) CHOLESTEROL** *q 5 YRS FOR AGE > 18 q YR IF PREV ABN

(6) HEARING CLINICAL DISCRETION

(7) SKIN EXAM (Cancer) ANNUAL IF AT RISK

(8) ORAL/DENTAL ** ANNUAL

(9) EYE/VISION**

ROUTINE ACUITY WITH PERIODIC

ASSESSMENT DIABETES ANNUAL

GLAUCOMA CHECK:

Blacks q 3-5 yrs age 20-29 All q 2-4 years age 40-64

(10) BREAST EXAM ANNUAL: > 40 YRS

(11) MAMMOGRAM** BASELINE @ 40, q 2 YRS

40-50, ANNUALLY > 50

(12) PAP

**(Digital Rectal Exam)

BASELINE: AGE 18 OR ONSET OF

SEXUAL ACTIVITY

AFTER 3 NL ANNUAL EXAMS,

PERFORM q 1-3 years.

(13) FECAL OCCULT

BLOOD

ANNUAL > 50 yrs

(14) SIGMOID EVERY 3-5 YRS: > 50 YRS

(15) COLONOSCOPY HIGH RISK q 5 YRS > 40 YRS

(16) TESTICULAR HIGH RISK ANNUAL 13-39 YRS

(17) PROSTATE**

**(DIGITAL RECTAL EXAM)

WITH P.E. > 40 YRS (Presently recommended annually)

(18) RUBELLA SCREEN

(Females)

ONCE BETWEEN AGES 12-18 YRS

(Unless prev vaccinated)

(19) OCCUPATIONAL

SCREENING EXAMS

APPROPRIATE TO EXPOSURES

(20)

(21)

(22)

DD FORM 2766, (Rev. 01-00) PAGE 2 of 4 PAGES

8. OCCUPATIONAL HISTORY/RISK

a. PRP YES NO

b. FLYING STATUS YES NO

9. IMMUNIZATIONS (Enter numeric class in sub block) (1)

IMMUNIZATION

(2) DATE

(ddmmmyyyy)

a. HEP A #1

b. HEP A #2

c. HEP B #1

d. HEP B #2

(1)

IMMUNIZATION

(2) DATE

(ddmmmyyyy)

f. MMR #1

g. MMR #2 h.

PNEUMOCOCCUS

i. POLIO OPV=O

IPV = I

(1)

IMMUNIZATION

(2) DATE

(ddmmmyyyy)

j. TD (q 10 YRS) (Last)

k. TD (DUE)

l. YELLOW

FEVER (LAST)

m. YELLOW

FEVER

(1)

IMMUNIZATION

(2) DATE

(ddmmmyyyy)

n. TYPHOID (Enter numeric class in sub block) Oral=O, TYPHUM

VI=1, TYPHOID USP = 2

(1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE

o. ANTHRAX

(1) INITIAL DATE (2) 2 WEEK DATE (3) 4 WEEK DATE (4) 6 MONTH DATE (5) 12 MONTH DATE (6) 18 MONTH DATE

p. PPD (Enter mm and date)

(1)(a) mm (2)(a) mm (3)(a) mm (4)(a) mm (5)(a) mm (6)(a) mm (7)(a) mm

(b) DATE (b) DATE (b) DATE (b) DATE (b) DATE (b) DATE (b) DATE

q. INFLUENZA (1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE (7) DATE

r. VARICELLA (1) DATE (2) DATE u. JAPANESE

ENCEPHALITIS

(1) DATE (2) DATE (3) DATE (4) DATE

s. MENINGO (1) DATE (2) DATE v. OTHER (Specify) (1) DATE (2) DATE (3) DATE

t. ADENO (1) DATE (2) DATE w. OTHER (Specify) (1) DATE (2) DATE (3) DATE

10. READINESS (Glucose-6-phosphate dehydrogenase)

a. DNA DATE: b. BLOOD

TYPE

DATE: RESULT: c. G-PD DATE: RESULT: d. SICKLE

CELL

DATE: RESULT:

e. PERMANENT PROFILE CHANGE (1) DATE (2) P: (3) U: (4) L: (5) H: (6) E: (7) S:

f. GLASSES/GAS/MASK Rx:

(1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE

g. DENTAL EXAM (Enter numeric class in sub block)

(1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE

h. HIV TESTING (1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE

i. FITNESS (in sub block enter P=Pass, F=Fail, W=Waiver)

(1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE

(1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE

(1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE

11. PRE/POST DEPLOYMENT HISTORY

a. LOCATION

(1) PREDEPLOYMENT (a) DATE (b) DATE (c) DATE (d) DATE (e) DATE (f) DATE

(2) POSTDEPLOYMENT (a) DATE (b) DATE (c) DATE (d) DATE (e) DATE (f) DATE

b. LOCATION

(1) PREDEPLOYMENT (a) DATE (b) DATE (c) DATE (d) DATE (e) DATE (f) DATE

(2) POSTDEPLOYMENT (a) DATE (b) DATE (c) DATE (d) DATE (e) DATE (f) DATE

c. CHART AUDIT

DD FORM 2766, (Rev. 01-00) PAGE 3 of 4 PAGES

(Continuation Sheet)

a. TEST b. FREQUENCY

DATES

(a) (b) (c) (d) (e) (f)

REMARKS

RECORDS MAINTAINED AT:

PATIENT’S NAME

LAST FIRST M.I.

SEX

RELATIONSHIP TO SPONSOR STATUS RANK/GRADE

SPONSOR’S NAME (Last, First, Middle Initial) DEPT/SERVICE

ORGANIZATION SSN/ID NUMBER DATE OF BIRTH

DD FORM 2766, (Rev. 01-00) PAGE 4 of 4 PAGES

ADULT PREVENTION AND CHRONIC CARE FLOWSHEET
b. OTHER ALLERGIES
ADULT PREVENTION AND CHRONIC CARE FLOWSHEET
8. OCCUPATIONAL HISTORY/RISK
YES
NO
YES

Untitled

other allergies:
chronic illness:
1:
2:
3:
4:
5:
6:
0:
7:
meds:
0:
1:
2:
3:
4:
5:
6:
7:
surgeries:
0:
1:
2:
3:
surgeries cont'd:
0:
1:
2:
3:
Fitness:
0:
1:
2:
3:
4:
11:
12:
13:
14:
20:
22:
23:
24:
21:
age:
0:
1:
2:
3:
4:
9:
11:
12:
13:
14:
20:
21:
22:
23:
24:
topic c:
med allergies:
Year:
1:
2:
3:
4:
5:
0:
Age:
0:
1:
2:
3:
4:
5:
lname:
fname:
MI:
sex:
Relationship:
stat:
rank:
Sponsor name:
dept:
org:
ssn:
dob:
Test:
0:
1:
3:
5:
6:
8:
9:
11:
13:
14:
16:
18:
19:
21:
22:
24:
26:
27:
freq:
0:
1:
3:
5:
6:
8:
9:
11:
13:
14:
16:
18:
19:
21:
22:
24:
26:
27:
test date:
0:
1:
3:
5:
6:
8:
9:
11:
13:
14:
16:
18:
19:
21:
22:
24:
26:
27:
test date b:
0:
1:
3:
5:
6:
8:
9:
11:
13:
14:
16:
18:
19:
21:
22:
24:
26:
27:
test date c:
0:
1:
3:
5:
6:
8:
9:
11:
13:
14:
16:
18:
19:
21:
22:
24:
26:
27:
test date d:
0:
1:
3:
5:
6:
8:
9:
11:
13:
14:
16:
18:
19:
21:
22:
24:
26:
27:
test date e:
0:
1:
3:
5:
6:
8:
9:
11:
13:
14:
16:
18:
19:
21:
22:
24:
26:
27:
test date f:
0:
1:
3:
5:
6:
8:
9:
11:
13:
14:
16:
18:
19:
21:
22:
24:
26:
27:
records:
reset:
clinical date2:
clinical date3:
clinical date4:
clinical date5:
clinical date6:
PRP No: Off
PRP YES: Off
Flying YES: Off
Flying No: Off
hepa #2:
hepb #1:
hepb #2:
hepa #1:
td:
td due:
yf:
yf date:
mmrs#1:
mmrs#2:
pneu:
polio:
immun a:
immunb:
immunc:
immund:
immun a name:
immunb name:
immund name:
immune cname:
typhoid3:
typhoid4:
typhoid5:
typhoid6:
typ sub block:
3:
6:
9:
12:
14:
0:
anthrax 2:
anthrax 3:
anthrax12:
anthrax 18:
anthrax4:
PPD:
0:
1:
2:
4:
5:
6:
8:
ppd date:
ppd date2:
ppd date 3:
PPD date 4:
ppd date5:
ppd date 6:
ppd date 7:
anthrax initial:
influenza:
0:
1:
2:
3:
4:
5:
6:
varicella:
0:
1:
3:
4:
5:
6:
meningo:
0:
1:
2:
4:
5:
6:
adeno:
1:
2:
4:
5:
6:
0:
DNA:
dna date:
blood:
blood date:
blood res:
g-pd:
g-pd date:
G-PD res:
sickle:
sickle cell date:
sickle result:
typhoid2:
typhoid1:
f:
0:
1:
2:
3:
4:
5:
g:
0:
1:
2:
3:
4:
5:
h:
0:
1:
2:
3:
4:
5:
i:
0:
1:
2:
3:
4:
5:
i cont:
0:
1:
2:
3:
4:
5:
i line 3:
0:
1:
2:
3:
4:
5:
Predeployment:
0:
1:
2:
3:
4:
5:
post:
0:
1:
2:
3:
4:
5:
predeployment contd:
0:
1:
2:
3:
4:
5:
post contd:
0:
1:
2:
3:
4:
5:
audit:
0:
1:
2:
3:
4:
5:
ppc:
2:
3:
4:
5:
12:
1:
Fitness sub:
4:
7:
10:
13:
16:
0:
dental sub:
0:
2:
4:
6:
8:
10:
rem:
clinical date:
0:
weight:
0:
1:
2:
3:
4:
5:
Height:
0:
1:
2:
3:
4:
5:
bp:
0:
1:
2:
3:
4:
5:
chol:
0:
1:
2:
3:
4:
5:
hearing:
0:
1:
2:
3:
4:
5:
skin:
0:
1:
2:
3:
4:
5:
oral:
0:
1:
2:
3:
4:
5:
eye:
0:
1:
2:
3:
4:
5:
mam:
0:
1:
2:
3:
4:
5:
pap:
0:
1:
2:
3:
4:
5:
fecal:
0:
1:
2:
3:
4:
5:
sigmoid:
0:
1:
2:
3:
4:
5:
colon:
0:
1:
3:
4:
5:
2:
testicular:
0:
1:
2:
3:
4:
5:
prostate:
0:
1:
2:
3:
4:
5:
rubella:
0:
1:
2:
3:
4:
5:
occ:
0:
1:
2:
3:
4:
5:
date 20:
0:
1:
2:
3:
4:
5:
date 21:
0:
1:
2:
3:
4:
5:
date 22:
0:
1:
2:
3:
4:
5:
breast:
0:
1:
2:
3:
4:
5:
PPC:
cancer:
card:
diabetes:
mental illness:
safe sex:
safe sex 2:
safe sex 3:
fp age:
2:
1:
0:
safe sex4:
fpage:
3:
4:
safe sex 5:
topic 2:
hormone:
topic 3:
topic 4:

File details come from the government source that posted it. Updated .