Attachment 21f DD 2808 Report of Medical Examination.pdf

DoD Form PDF 745 KB Posted Jul 29, 2011

Attached to: Occupational Health Services
Solicitation number: SP4702-11-R-0001
Issued by: Defense Logistics Agency Land and Maritime

About this file

From the source

Attachment 21f

View the file

Other versions and copies of DD Form 2808

5 government files on GovTribe name DD Form 2808. Different revisions are separate documents; copies of this exact file point search engines to its first posting.

File	Revision	Posted	Attached to
PWS Attachment 23 DD Form 2808 Report of Medical Examination.pdf	Revision not stated	May 24, 2022	United States Army Reserve Command (USARC) Physical Exams
47QFWA22R0008 Appendix C - DD Form 2808.pdf	Revision not stated	Mar 29, 2022	DoDMERB Medical Services
Attachment_16_DD2808.pdf	Revision not stated	Oct 17, 2013	Occupational Healthcare and Medical Services for NIOSH Morgantown
Attachment 16 DD2808.pdf	Revision not stated	Feb 27, 2009	Occupational Healthcare and Medical Services for NIOSH Morgantown

Who attaches DD Form 2808

Agency	Files
Department of Health and Human Services Centers for Disease Control and Prevention Pittsburgh	2
General Services Administration Federal Acquisition Service Assisted Acquisition Services Region 7	1
Department of the Army Medical Command	1
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	Aug 22, 2011
SP4702-11-R-0001 Amendment 0002 pgs 2-11.pdf	PDF	Aug 22, 2011
Amend 0001 11-R-0001 Pg1.pdf	PDF	Aug 15, 2011
Attachment 21d OF178 Example for Deployment.pdf	PDF	Aug 15, 2011
Attachment 26 Health Promotions Screenings.doc	DOC document	Aug 15, 2011
Attachment 7 DLA inj.docx	DOCX document	Aug 15, 2011
Amendment 0001 Replacement pages.pdf	PDF	Aug 15, 2011
Amendment 0001 SP4702-11-R-0001.pdf	PDF	Aug 15, 2011
Attachment 18 Radiation monitoring.pdf	PDF	Aug 15, 2011
Attachment 33 Foreign Travel Vacination Review.pdf	PDF	Aug 15, 2011
Attachment 2 Govt Property.xls	XLS spreadsheet	Aug 15, 2011
Attachment 31 WD05-2417(Rev.14) Amend 0001.pdf	PDF	Aug 15, 2011
Attachment 6 DFAS inj.docx	DOCX document	Aug 15, 2011
Attachment 8 DISA inj.docx	DOCX document	Aug 15, 2011
Attachment 21d OF 178 Example for Pre-employment Medical Surveillance.pdf	PDF	Aug 15, 2011
Attachment 7 DLA inj.docm	DOCM document	Jul 29, 2011
Attachment 8 DISA inj.docm	DOCM document	Jul 29, 2011
Attachment 25 DA Form 5006-R Authorization for Disclosure of Information.pdf	PDF	Jul 29, 2011
Attachment 23 DoDI 6200.03 Public Health Emergency Mgmt within DoD.pdf	PDF	Jul 29, 2011
Attachment 6 DFAS inj.docm	DOCM document	Jul 29, 2011
Attachment 30.xlsx	XLSX spreadsheet	Jul 29, 2011
Attachment 5 Refusal of Medical Services.pdf	PDF	Jul 29, 2011
Attachment 14 CA16.pdf	PDF	Jul 29, 2011
Attachment 13 CLIN sheet .docx	DOCX document	Jul 29, 2011
Attachment 19 Mod 10 to USCENTCOM Indiv Protectection Indiv Unit Deployment.pdf	PDF	Jul 29, 2011
Attachment 4 Potential exposure to BBP.pdf	PDF	Jul 29, 2011
Attachment 21a DD2795 Pre Deployment Health Assessment.pdf	PDF	Jul 29, 2011
Attachment 11 CA1.pdf	PDF	Jul 29, 2011
Attachment 20 PPG-Tab A To accompany Mod 10.pdf	PDF	Jul 29, 2011
Attachment 29.xls	XLS spreadsheet	Jul 29, 2011
Attachment 21h BMI for Deploying DoD Civilians to SWA.pdf	PDF	Jul 29, 2011
Attachment 31-DOL 05-2417 dtd 9.14.10.pdf	PDF	Jul 29, 2011
List of Attachments.docx	DOCX document	Jul 29, 2011
Attachment 10 CA20.pdf	PDF	Jul 29, 2011
Attachment 21c DD2766 Adult Prevention and Chronic Care Flowsheet.pdf	PDF	Jul 29, 2011
Attachment 21g OSHA Respirator medical Evaluation Questionnaire.pdf	PDF	Jul 29, 2011
Attachment 28 Privacy Act Statement - Health Care Records.pdf	PDF	Jul 29, 2011
Attachment 16 Equipment Supplement.doc	DOC document	Jul 29, 2011
Attachment 22 CENTCOM Medical waiver Request Documentation.pdf	PDF	Jul 29, 2011
Attachment 1 Security Safety Fire.doc	DOC document	Jul 29, 2011
Attachment 24 Government Records.doc	DOC document	Jul 29, 2011
Attachment 21b DD2813 DoD Active Reserve Forces Dental Examination.pdf	PDF	Jul 29, 2011
Attachment 17 Police Officers.pdf	PDF	Jul 29, 2011
Attachment 9 Medical Officer Report.pdf	PDF	Jul 29, 2011
Attachment 27 DSCC 2278-AED Class Registration Form.pdf	PDF	Jul 29, 2011
Attachment 21i DD2807-1 Report of Medical History.pdf	PDF	Jul 29, 2011
SF 1449 PAGE 1.pdf	PDF	Jul 29, 2011
Attachment 3 Weather Emergencies.doc	DOC document	Jul 29, 2011
Attachment 21e DD FORM 771 EYEWEAR PRESCRIPTION.pdf	PDF	Jul 29, 2011
Attachment 21d SF78 Certificate of Medical Examination.pdf	PDF	Jul 29, 2011

Show 40 more

Latest 50 of 56 listed here. See the rest on GovTribe.

On GovTribe

Work with this file

Download the original file
Contacts named in this file
Similar government files
Ask GovTribe AI about this file

Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

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/

62. REFRACTION BY AUTOREFRACTION OR MANIFEST

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

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

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.

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

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

examdate:

homeaddr:

homephone:

grade:

birthdate:

age:

sex: Off

xamerind: Off

xasian: Off

xblack: Off

xwhite: Off

xpacific: Off

xethnic: Off

milyrs:

civyrs:

agency:

org:

rating:

totalfly:

lastsix:

xservice: Off

xcomp: Off

xpurpose: Off

examloc:

x17: Off

x18: Off

x19: Off

x20: Off

x21: Off

x22: Off

x23: Off

x24: Off

x25: Off

x26: Off

x27: Off

x28: Off

x29: Off

x30: Off

x31: Off

x32: Off

x33: Off

x34: Off

x35: Off

x36: Off

x37: Off

x38: Off

x39: Off

x40: Off

x41: Off

x42: Off

xdental: Off

dentclass:

notes:

appname:

ssn:

albumin:

sugar:

URINE_HCG:

HH:

BLOOD_TYPE:

HIVresults:

drugresults:

alcresults:

papresults:

othertest1:

otherresults1:

othertest2:

otherresults2:

HIV_SPECIMEN_ID_LABEL:

DRUG_TEST_SPECIMEN_ID:

HEIGHT:

weight:

MIN_WGT__MAX_WGT:

MAX_BF:

TEMPERATURE:

PULSE:

SYS1:

SYS2:

SYS3:

DIAS1:

DIAS2:

DIAS3:

REDGREEN:

OTHER_VISION_TEST:

Right_20:

Corr_to_20:

Left_20:

Corr_to_2:

By1:

By_S:

CX1:

By2:

By_S1:

CX2:

Right_1:

Corr_to_1:

by3:

Left_1:

Corr_to_3:

by4:

es:

ex:

rh:

lh:

prism:

ct:

npr:

pd:

Right:

Left1:

PIP:

14:

afvt:

Uncorrected:

Corrected:

FIELD_OF_VISION:

NIGHT_VISION:

OD:

OS:

71a_Unit_Serial_Number:

71a_Date_Calibrated:

Reset:

xqual: Off

examsign:

signdate:

date1:

qual1: Off

summary:

recommendations:

WKID1:

ST1:

mepsdate1:

mepsinit1:

WKID4:

ST4:

mepsdate4:

mepsinit4:

WKID2:

ST2:

mepsdate2:

mepsinit2:

WKID5:

ST5:

mepsdate5:

mepsinit5:

WKID3:

ST3:

mepsdate3:

mepsinit3:

WKID6:

ST6:

mepsdate6:

mepsinit6:

HT1:

WT1:

BF1:

MAX_WT1:

HCG1:

inspqual1: Off

HT2:

WT2:

BF2:

MAX_WT2:

HCG2:

insp_date3:

HT3:

WT3:

BF3:

MAX_WT3:

HCG3:

insp_date4:

HT4:

WT4:

BF4:

MAX_WT4:

HCG4:

insp_date5:

HT5:

WT5:

BF5:

MAX_WT5:

HCG5:

phys_name1:

phys_sign1:

phys_name2:

phys_sign2:

dent_name1:

dent_sign1:

dent_name2:

dent_sign2:

revsign:

revgrade:

revdate:

xwaiver: Off

waiver:

sheets:

appl: Adobe Professional 7.0

insp_date1:

insp_date2:

inspsign1:

inspsign2:

inspsign3:

inspsign4:

inspsign5:

inspqual3: Off

inspqual4: Off

inspqual5: Off

item1:

P1:

U1:

L1:

H1:

E1:

S1:

X1:

prof_init1:

date2:

P2:

U2:

L2:

H2:

E2:

S2:

X2:

prof_init2:

P3:

U3:

L3:

H3:

E3:

S3:

X3:

prof_init3:

date3:

P4:

U4:

L4:

H4:

E4:

S4:

X4:

prof_init4:

date4:

P5:

U5:

L5:

H5:

E5:

S5:

X5:

prof_init5:

date5:

item2:

cond1:

icd1:

prof_ser1:

rbjdate1:

examinit1:

svc_1:

waivdate1:

cond2:

icd2:

prof_ser2:

rbjdate2:

examinit2:

svc_2:

waivdate2:

item3:

cond3:

icd3:

prof_ser3:

rbjdate3:

examinit3:

svc_3:

waivdate3:

item4:

cond4:

icd4:

prof_ser4:

rbjdate4:

examinit4:

svc_4:

waivdate4:

item5:

cond5:

icd5:

prof_ser5:

rbjdate5:

examinit5:

svc_5:

waivdate5:

qual2: Off

qual3: Off

qual4: Off

qual5: Off

inspqual2: Off

r_500_a:

r_1000_a:

r_2000_a:

r_3000_a:

r_4000_a:

r_6000_a:

l_500_a:

l_1000_a:

l_2000_a:

l_3000_a:

l_4000_a:

l_6000_a:

71b_Unit_Serial_Number:

71b_Date_Calibrated:

r_500_b:

r_1000_b:

r_2000_b:

r_3000_b:

r_4000_b:

r_6000_b:

l_500_b:

l_1000_b:

l_2000_b:

l_3000_b:

l_4000_b:

l_6000_b:

read_aloud: Off

valsalva: Off

notes_contd:

xnormarch: Off

xcavus: Off

xplanus: Off

xmodfeet: Off

xmildfeet: Off

xsevfeet: Off

xasimfeet: Off

xsymfeet: Off

File details come from the government source that posted it. Updated Nov 14, 2017.