Docstoc

MEB Soldier Briefing MEET THE STAFF

Document Sample
MEB Soldier Briefing MEET THE STAFF Powered By Docstoc
					Madigan Army Medical Center

       Welcome to
Medical Evaluation Boards
         (MEBs)




                              1
Please Silence ALL Phones,
    PDA’s, and Pagers.




                             2
      DA 5893
      Counseling Checklist




                             3

Checklist # 1
          BLUE PACKET CONTENTS
          Left Pocket              Right Pocket

          MAMC Briefing Slides     Personnel Data letter
          MEDCOM Briefing Slides   TSGLI
          APDES Handbook           ACAP Transition Svc
          FACT Sheet (TAMP)        Legal Svc Information
                                   My MEB (AKO)


                                                           4

Checklist # 5
   GOALS for Today’s Briefing

1. Introduce you to Medical Evaluation Board (MEB)
   Process


2. Introduce you to Physical Evaluation Board (PEB)
   Process


3. Answer common MEB/PEB questions


                                                      5
A Few ACRONYMS

MEB = Medical Evaluation Board
PEB = Physical Evaluation Board
PEBLO = PEB Liaison Officer
MEBT = Medical Evaluation Board Technicians
NARSUM = Narrative Summary (or dictation)
WTB/WTU = Warrior Transition Battalion (Unit)
                                                6
  The MAMC MEB Staff

Medical Board Technicians & Clerks: Make your
 appointments, track board through the process.

Ms. Paige       A-C                   968-1638
Ms. Coleman     D-G, POM, CBWTU       968-5057
Ms. Edwards     H-L                   968-5058
Mr. Der         M-R                   968-3438
Mr. Espinoza    S-Z                   968-3744
Ms. English     TDRL                  968-1855

                                                  7
The MAMC MEB Staff (cont’d.)
PEBLOs
 Physical Evaluation Board Liaison Officers (PEBLOs): Review board
 packet, counsel soldiers on benefits and appeals.



 Ms. Burnham                 A-B, POM              968-2026
 Ms. High                    C-F                   968-6019
 Ms. Johnson                 G                     968-3437
 Ms. Levene                  H                     968-2564
 Ms. Miracle                 I-L, CBWTUC           968-1679
 Ms. Robinson                M-R                   968-3649
 Ms. Gorden                  S-Z                   968-3686
                                                                     8
Office Hours


         Walk- In Hours
        1000 - 1600 HRS
   Monday - Wednesday & Friday


CLOSED EVERY THURSDAY
     CLOSED on Federal Holidays
       ** Inclement Weather**
                                  9
WHAT IS PDES?
 The entire Physical Disability Evaluation System


 2 Parts MEB and PEB


 MEB - Medical evaluation Board
     - Gathers together the medical information
 PEB - Physical Evaluation Board
     - Determines disability percentage based on
      medical information
                                                     10
 MEB / PEB: “6 Letters, 6 Steps”

1. PHYSICAL EXAM


          2. CONSULTS


               3. NARRATIVE SUMMARY (NARSUM)


                        4. MEB REVIEW


                                    5. PEB


                                               6. PDA
                                                        11
      DA Physical Disability Process
                                                                    MAMC Responsibility:
                                                                    •Washington, Idaho,
                                                                    California (incl. CBWTUC),
  Physician                                                         Oregon, & Nevada
  MMRB                                                              •AC, RC, & TDRL
  FFD

              MEB Initiated


                                     MEB

                                                      PEB
            MAMC                                  at Ft. Lewis
         Responsibility
   Standard = 90 workable days                                            PDA
Madigan Average = 92 workable days                                       in D.C.

                                                                                      Orders
                        PEBLO Counsels Soldier & Assists VA Transition
                                                                                        12
How long does it take to complete a
Medical Board?

From the time you are notified, by
 the MAMC MEB staff that you will
undergo a Medical Board, our goal
   is to send the case to the PEB
       within 90 workable days.

  THIS IS ONLY AN ESTIMATE            13
What is a Medical Board?

         It is a “word picture” of
         your medical condition,
            military history and
                  lifestyle.



                                     14
How did I become a Medical Board?
  3 Ways to become an MEB:

    1. Referred by a Fitness For Duty
       Evaluation (Commander)

    2. Referred by MMRB (Medical MOS
       Reclassification Board)

    3. Referred by Doctor* (most common)   15
A Medical Board is NOT...

 An MOS reclassification Board (MMRB) -
 any MOS reclassification would have
 occurred at the MMRB.

 You WILL NOT sit in front of a panel of
 board members. The MEB is simply a
 physician’s evaluation and
 recommendation.
                                            16
History & Physical Examination
     (DD 2807 & DD 2808)

   When you complete your
 forms (DD 2807 & DD 2808),
    address ANY and ALL
 medical conditions which you
            have.

                                 17
Consults
 If your MEB Provider wants you to be evaluated
    by another specialty clinic, they will request a
      consult with that clinic. Please notify your
          MEBT ASAP when this happens.


    DO NOT CALL TRICARE FOR AN
    APPOINTMENT – SEE YOUR MEBT!


                                                       18
Narrative Summary (NARSUM)

  It is in your best interest, to tell your MEB
  Provider about any & all medical problems
      you have. If necessary, they will be
    reviewed and addressed in your board.


   Your MEB Provider CANNOT
   read your mind. If you do not
    tell them all your problems,
        they cannot help you.
                                                  19
What are the possible MEB
recommendations?

  The MEB Provider can recommend:
   Return to Unit without limitations
   Return to Unit with limitations
   Refer to Physical Evaluation Board (PEB)
   Other

                                              20
MEB Review: Who reviews my MEB?

 1st: Two Doctors, your board doctor and one
   other doctor
 2nd : YOUR PEBLO
 3rd: The Madigan Deputy Commander for
   Clinical Services (or his representative)

 4th: YOUR PEBLO


                                               21
         Independent Review (IR)
       An independent review is an opportunity for an
          independent medical provider to review your
          COMPLETED medical board.
       They will determine if the board has been
          adequately completed and will provide you written
          documentation to support any missing diagnosis.
       The information they provide you can assist you
        with your appeal.
       All information pertaining to your IR will be
        forwarded to the PEB with your case.
                                                          22

Checklist # 16 &19
    APPEAL VS STATEMENT
 SHOULD I APPEAL??             S
                                H
                                O
                                U
                                L
                                D
                                I
                                D
                                O

                                B
                                O
 SHOULD I MAKE A STATEMENT??   T
                                H 23
Can I write on my behalf?

 If you feel you have information which
    would help the MEB/PEB, you can
   write a statement on your own behalf,
     which will be included in your PEB
                   packet.


                                           24
Can I appeal the MEB?
 Yes.
 You have 7 calendar days to review board.
 Decision for IR will be decided during this
 time. The PEBLO will attempt to schedule
 your appointment within 5 days. You will
 have 7 calendar days (from the date of your
 appointment) to make your election of
 concur/nonconcur (appeal).

                                               25
MEB Packet

è Coversheet (DA 3947)
è Narrative Summary (NARSUM/dictation):
  written by your doctor. Provides a “word
  picture” of your condition, history and status.
  Provides a recommendation.
è Consults from clinics you visited.
è Current History & Physical (DD 2807 &
  2808).
è Copy of your profile.
                                                    26
Personnel Data**
è ERB/ORB/PQR
è Commander’s Performance Statement
è NCOERs/OERs (E-5 And above) (Last 3)
è DA 4187 (Name changes, loss of rank,
  promotions, etc)
è DA 2648 (COMPLETED ACAP Checklist)
è LES (Current End of Month)


**RC soldiers may have additional requirements.
                                                  27
28
Completed PEB Packet

   MEB PACKET
   PERSONNEL DATA
   HEALTH RECORD




                       29
 Line of Duty (LOD)

 A LOD is may be required for any condition
 that is the direct result of an accident or injury
 which occurred while entitled to Active Duty
 Pay.


Examples: Motor Vehicle Accident,
 Misconduct, Drugs, Alcohol, TPU/M-Day
 soldiers
                                                  30
What about flags or UCMJ?
  Court martial procedures will stop your medical
                       board.
 Chapter 14 is done in conjunction with the medical
    board. Which action has precedence will be
      determined once the MEB is completed.
All other Chapters are put on hold until the Medical
                Board is completed.

 Immediately report any flags or adverse actions to
                    your PEBLO
                                                       31
         What if I am about to ETS?

             Soldiers can be retained medically for the
                 purpose of completing the medical
                          evaluation board.
             NOTIFY YOUR PEBLO 30 Days PRIOR!

                   ENLISTED - 6 month Interval
                   OFFICER - 3 month Interval

                                                          32

Checklist # 23
What if I am about to PCS?
 Soldiers who come down on PCS orders or are
     currently on orders cannot PCS until the
            Medical Board is complete.

     NOTIFY YOUR MEBT IMMEDIATELY

 Your MEBT will obtain the paperwork necessary
    to delete or defer your PCS orders until the
                  board is complete

                                                   33
 What if I put in for retirement?


                   DON’T

Soldiers who have submitted for retirement
   and have received orders will have their
    orders revoked until completion of the
               Medical Board.
                                              34
**NOTIFY YOUR PEBLO IMMEDIATELY**
          Is there any way I can stay in?

             YES, you can request Continuation on Active
                 Duty/Active Reserve Component (COAD/COAR).


                      CRITERIA FOR CONSIDERATION:
                       15 YEARS BUT LESS THAN 20
                             SHORTAGE MOS
                        INJURY COMBAT RELATED

                        HRC MAKES THE DECISION
                             NOT THE PEB
                                                              35

Checklist # 17
PEB: What does the Physical
Evaluation Board Do?

  The PEB reads all documentation
   and determines your fitness
   status:
         “FIT FOR DUTY”
                or
        “UNFIT FOR DUTY”
                                    36
There are 2 types of Fit For Duty

            NORMAL FIT FOR DUTY
You are found fit because you can do the
  majority of your duties in your current MOS.

       PRESUMPTIVE FIT FOR DUTY
You have submitted for retirement or are at your
  Retention Control Point (RCP).


                                                   37
Can I appeal a FIT for DUTY?
              YES

  The PEB President will decide
   if you will appear in front of
         a formal board.


                                    38
“FIT for DUTY”
  Once you have been found FIT for DUTY, you
  will receive a FIT letter from the Physical
  Disability Agency, you will be released from all
  restrictions imposed during the medical board
  process (i.e. You are now deployable).


  YOUR MEB PERMANANT PROFILE WILL
  BECOME A PART OF YOUR MEDICAL
  RECORDS.

                                                     39
“UNFIT for DUTY”

When the PEB determines UNFIT for DUTY,
they also determine the % of unfitness.

 ----%   Existed Prior to Service (EPTS)
0% - 20% Severance Pay Calculation
30% or   Medical Retirement


                                           40
Existed Prior to Service (EPTS)

  Separation is given without Disability
      Benefits (monetary or medical)
        [Exception “8 Year Rule”]
  ***LIMITED BENEFITS ARE GIVEN
       THROUGH INVOLUNTARY
              SEPARATION
 ***SEE TRANSITION POINT WALLER
               HALL
                                           41
            0 - 20 % - Severance Pay
                 2 MONTHS BASE PAY FOR EACH YEAR OF
                      ACTIVE SERVICE (UP TO 19 YRS)

                      2 X Month Base Pay X #YRS

                 EXAMPLE: 6 YEARS 10 MONTHS ACTIVE
                          SERVICE WOULD BE
                    2 X MONTH BASE PAY X 7 = $$$

                          NEW!! NEW!! NEW!!
                      Non-Combat - Minimum 3 years
                    In Combat Zone – Minimum 6 years
                                                       42

Checklist # 40
Combat Zone Vs Combat Related
 Combat Zone
     Any injury or illness that occurs in a combat Zone.
          (example: Tripped and fell walking to the mess hall,
           while deployed in Iraq)


 Combat Related
     Any injury or illness that occurs while engaged in a
      combat mission.
          (example: IED blast while on patrol)


                                                                  43
0 - 20% - Severance Benefits

   In addition to Severance Pay, you and your
   family are entitled to the following:


              Medical Care
               180 days

                                                44
Medical Retirement - 2 types
Temporary Disability Retirement List (TDRL)
  - Re-evaluated every 18 months
  - Can be retained a maximum of 5 years

Permanent Disability Retirement List (PDRL)
  - Permanent Retirement




                                              45
Retirement Benefits
Eligible for all benefits awarded to 20 year
  length of service retirees:


     MEDICAL THROUGH TRICARE
     DENTAL THROUGH TRICARE
       COMMISSARY AND PX

                                               46
Can I appeal this recommendation?
 If you disagree with an “UNFIT for DUTY” determination,
 you can appeal in two ways:
     1. IN WRITING
     2. REQUEST A FORMAL BOARD with LEGAL
     REPRESENTATION

   YOU HAVE 10 CALENDAR DAYS TO MAKE YOUR
                   DECISION

 NOTE:
  If you choose to appeal in writing, and the appeal is rejected, you
                                                                        47
    may lose your right to request a formal board.
PDA – Physical Disability Agency
 Once your case has been completed by the PEB, it is
  forwarded to the Physical Disability Agency for final review.

 After PDA processing, you will be placed on TRANSPROC
  for orders.

 Once you are on TRANSPROC, your PEBLO will contact
  you so you can go to Waller Hall (transition) to pick up your
  packet. Your command will need to sign a 4187 so you can
  go back to transition and get your final orders. Please give
  a copy to your PEBLO as soon as you receive your final
  orders so your case can be closed.
                                                              48
LEAVE/PERMISSIVE TDY


     Your Command
      will determine
    what leave and/or
    Permissive TDY will
       be granted.        49
What about Additional Benefits?

If you are separated or medically
retired, Your PEBLO will:
 Refer you to the VA to start your
  claim
 Refer you to the TRICARE Service
  Center
 Discuss other services available
  on an individual basis
                                      50
       What about confidentiality?
               (HIPPA)
 Your medical board is personal and private.
 Limited information can be provided to your unit:
      IF YOU ARE A MEDICAL BOARD
      WHAT IS THE BOARD’S CURRENT
       STATUS
      IF YOU WERE FOUND FIT OR UNFIT
Family members do not have automatic access to your
           medical records/board status.

       KEEP EVERYONE CONCERNED INFORMED.
                                                      51
PTSD
(Post Traumatic Stress Disorder)
 The Diagnosis of PTSD may be given when a traumatic
  event (stressor) has occurred, in which the soldier
  experienced, witnessed or was confronted with actual or
  threatened death or serious injury or threatens the physical
  integrity of the Soldier or of others.”

 NOTE: Combat does not automatically justify a
  diagnosis of PTSD




                                                                 52
PTSD
(Post Traumatic Stress Disorder)
 Any additional information can help the PEB make
  their final determination.

Types of information could be:

 Statement from your in-theater commander

 Statements from fellow Soldiers who witnessed
  the same events with you.

                                                 53
          Resources
           There are additional resources available to you
                throughout this process.

           WTB Contact Rep
           Case Manager
           Legal Counsel
           Ombudsman



                                                              54

Checklist # 7
WTB Contact Representatives
Assist with Personnel Data for WTB Soldiers.

 A CO          Wilma Agular           966-2567
 B CO          Floretta Stevens       966-2715
 C CO          Monique Baker          966-2958




                                                  55
Case Manager

Continues coordinating all your
 medical (non-MEB) appoints.

Continue working with your case
 manager if you have questions.


                                   56
         Legal Counsel (FLOSC)
          Ft Lewis Office of Soldier’s Counsel (FLOSC) is
             available to help soldiers throughout the different
             stages of the MEB and PEB.

          Advise and represent you, not commanders or
             members of the MEB/PEB, about your legal rights
             as you work through your medical board.

          Give a general overview briefing daily or you can
             meet individually with an attorney.
                                                                   57

Checklist # 10
         Ombudsman
          The Ombudsman team provides a neutral and informal
             process to assist Warriors in Transition and their Family
             Members. Emphasis includes:
               Health care issues, Physical disability processing,
                Medical retention, Finance, Legal, Transition benefits,
                VA, TSGLI

          Assist with writing appeals (at any stage of the board)


          Ombudsman
                    Ador Yabut 253-320-9725

                                                                          58

Checklist # 30
      Every SOLDIER will be able to track the progress of their
      MEB/PEB via the My MEB Portal on AKO.

           There are two ways to access you’re my MEB:

           Type the following address into your Internet Browser
           https://www.us.army.mil/suite/page/417118
                                     Or

           From your AKO homepage click on
           Self Service / My Medical / My MEB
                                                                  59

Checklist # 3
How can I make this as
painless as possible?

                         60
IGNORE RUMORS

 All cases are unique. Until
 the PEB makes a
 determination, NO ONE
 KNOWS WHAT THE
 OUTCOME WILL BE.

                               61
BE AVAILABLE
Always provide accurate phone
numbers.

If you change units or assignments,
let your PEBLO know.

Never leave town without telling
your PEBLO.
                                      62
BE AT YOUR APPOINTMENTS

    Don’t miss any of your
         appointments
 Be on time with your ID card
   Be in the appropriate
           Uniform
    Be prepared to wait
                                63
What happens if you miss a
MEB Appointment?

 You will be escorted to EVERY MEB
  appointment if you are late or do not show up.


 It is YOUR responsibility to show up to your
  appointments at least 15 minutes early.


 Your unit will be required to provide the escort.
                                                      64
BE INFORMED
  Ask questions. Ask how long each
 step should take and follow-up. This
   is YOUR career and YOUR board.
 Take the time to review all documents
  for accuracy. Provide accurate and
           timely information.

      YOU ARE THE KEY TO
        YOUR BOARD.
                                         65
Our Address & Phone Number

MADIGAN ARMY MEDICAL CENTER
ATTN: MCHJ-PDP (PEBLO)
9040 REID STREET
TACOMA, WA 98431

FAX: (253) 968-1678
DSN 782-1678

                              66
             ?
QUESTIONS?



                 67
MEB INTAKE FORMS

 Initiate Board paperwork
      Soldier Data Sheet
      DD Form 2807-1(Medical History)
      DD Form 2808 (Physical Exam)
      DD Form 2870 (Privacy Statement)
      MEDCOM Form 756-r (E-mail authorization)



                                                  68
                                                              Medical Evaluation Board
                                                                 Soldier Data Sheet

 Soldier               Tech
                       LAST name:
                                          ADMIN ONLY

                                                PEBLO
                                                                           FIRST name:                                  MI:




 Data Sheet            SSN:


                       LOCAL Mailing Address:
                                                            GENDER (circle one)
                                                                      Male            Female
                                                                                               BIRTH DAY: MMDDYYYY


                                                                                               Were you deployed to: Nobel Eagle
                                                                                                                                    AGE:




                                                                                               (circle all that apply) None
                                                                                               Operation Iraq Freedom
                       CITY:                                STATE:         ZIP CODE            Operation Enduring Freedom
                                                                                               Operation Joint Guardian

Please Write Legibly   CIRCLE       I AM LEFT HANDED                                           LOCAL Phone: (          )
                       ONE          I AM RIGHT HANDED                                          Home Phone:  (          )
                                                                                               Cell Phone:  (          )
                       Have you applied for Retirement or Early Release?     YES         NO    Unit Phone:  (          )
                                                                                               Duty Phone:  (          )
                                                                      Please only circle ONE
                           Active Component     USAR-AGR     USAR-weekend       USAR-Mobilized    NG-AGR      NG-Mobilized    NG-M-day
                       If you are in the USAR, what RSC? ____________________ If you are in the NG, what state? ________________
                       RANK:                    PAY GRADE:            PMOS/AOC:                           PEBD:
                                                                                                          MMDDYYYY
                                                                      Description:
                       Basic Active Service Date:          TOTAL Active Duty Time:            (USAR/NG ONLY)        (USAR/NG ONLY)
                       MMDDYYYY:                                                              Good Years:           End MOB Date
                                                           Years:        Months:                                    MMDDYY:
                       Current Tour of Duty:               ETS Date
                       MMDDYYYY:                           MMDDYYYY:

                       Unit Name:               Company:                   Brigade:            UIC:                     Duty Station:


                       FULL UNIT Mailing Address:

                       ________________________________________________            _______________           _______        ____________
                       Street Address                                              City                      State               Zip
                       Why are you being Boarded? (List ONE condition ONLY, all other medical problems list on back)

                       If you are found UNFIT, do you want a waiver to remain on Active Duty or in the Reserves?        YES         NO

                                                                             ADMIN ONLY
                       if Refered by MMRB, date the board convened:


                       If Doctor Refferred, List DOCTOR, CLINIC, and DATE on pink slip

                       DOCTOR                                              CLINIC                          DATE


                       Briefing Date                        PEBLO interviewed                  Tech Interviewed
                                                                                                                                           69
                       DOCTOR                                              CLINIC                          DATE


                       Date Interviewed                     PEBLO interviewd                   Tech Interviewed
                                                                                                             1 . DATE OF EX AMINATION                            2 . SOCIAL SECURITY NUMBER
                             REPORT OF M EDICAL EX AM INATION                                                    (YY YYMMDD)

                                                                                                                                                                       555-55-5555
                                                                                             PRIVACY ACT STATEMENT

DD form 2808                                                                                             .
               AUTHORITY: 1 0 USC 50 4 , 5 05 , 5 0 7, 53 2 , 9 78 , 1 2 01 , 1 2 02 , and 4 34 6 ; and E O. 9 39 7 .
               PRINCIP AL PURP    OSE(S): To obt ain medical dat a f or det erminat ion of medical f it ness f or enlist ment, induct ion, appoint ment and ret ent ion f or
               applicant s and members of t he Armed Forces. The informat ion w ill also be used f or medical boards and separat ion of Service members f rom

   Page 1      t he Armed Forces.
               ROUTINE USE(S): None.
               DISCLOSURE: Volunt ary; how ever, f ailure by an applicant t o provide t he inf ormat ion may result in delay or possible rejection of t he
                                                                         or
               individual' s applicat ion t o ent er t he Armed Forces. F an Armed Forces member, f ailure t o provide t he inf ormat ion may result in t he individual
               being placed in a non-deployable st at us.

                   3 . LAST NAME - FIRST NAME - MIDDLE NAME                     4 . HOME ADDRESS (St reet , A part ment Number, Cit y, St at e and ZIP Code)                       5 . HOME TELEPHONE
                                                                                                                                                                                       NUMBER
                     (SUFFIX )
                                                                                      123 my street                                                                                    (Include A rea Code)

                                                                                                                                                                                   (253) 555-4321
               Joe, Gerold I.
                   6 . GRADE       7 . DATE OF BIRTH           8 . AGE    9 . SEX
                                                                                      Ft Lewis, WA 98433
                                                                                          1 0 .a. RACIAL CATEGORY (X one or more)                                                  b. ETHNIC CATEGORY



                                                                                                                                                                                                          *
                                      (Y YYYMMDD)                                                 A merican Indian or          Black or A f rican       Nat ive Haw aiian or

                    E-5            1974/04/16                   30             Female             A laska Nat ive              A merican                Ot her Pacif ic Islander      Hispanic/ Lat ino
                                                                                                                                                                                      Not Hispanic/
                                                                                                                                                                                                              Decline
                                                                                                                                                                                                              to


                                                                          *                                                                         *
                                                                               Male               A sian                      Whit e                    Decline to Respond            Lat ino                 Respond
               1 1 . TOTAL YEARS GOV ERNMENT                  1 2 . AGENCY (Non-Service Members Only)                                               1 3 . ORGANIZATION UNIT AND UIC/CODE
                     SERV ICE
                 a. MILITARY
                    9 yrs
                                 b. CIVILIAN
                                           6 yrs              Post Office                                                                                29 sig bn / WEJGT0
               1 4 .a. RATING OR SPECIALTY (A viat ors Only)                  b. TOTAL FLYING TIME                                                   c. LAST SIX MONTHS


               1 5 .a. SERV ICE                   b. COMPONENT                c. PURPOSE OF EX AMINATION                                            1 6 . NAME OF EX AMINING LOCATION, AND ADDRESS
                                      Coast                                                                                                               (Include ZIP Code)


                                                   *
                      A rmy                                                         Enlist ment              Medical Board              Ot her

               *                                                                                      *
                                      Guard              A ct ive Dut y
                      Navy
                                                         Reserve
                                                                                    Commission               Ret irement                                MAMC
                      Marine Corps
                      A ir Force
               CLINICAL EVAL
                                                   *
                                                   *
                                                         Nat ional Guard
                                                                                    Ret ent ion
                                                                                    Separat ion
                                                                                                             U.S. Service A cademy
                                                                                                             ROTC Sch olarship Program
                            UATION (Check each it em in appr opriat e column. Ent er " NE" if not evaluat ed.)
                                                                                                                                                        Tacoma, WA 98433

                                                                                                      Nor-   Ab-    NE     4 4 . NOTES: (Describe every abno rmalit y in det ail.       Ent er pert inent it em
                                                                                                      mal    norm
               1 7 . Head, f ace, neck, and scalp                                                                              number bef o re each commen t . Cont inue i n it em 7 3 and use addit ional
                                                                                                                               sheet s if necessary.)
               1 8 . Nose
               1 9 . Sinuses
               2 0 . Mout h and t hroat
               2 1 . Ears - General (Int . and ext . canals/A udi t ory acuit y under it em 7 1 )
               2 2 . Drums (Perf orat ion)
               2 3 . Eyes - General (V isual acuit y and r ef ract ion under it em s 6 1 - 6 3 )
               2 4 . Opht halmoscopic
               2 5 . Pupils (Equalit y a nd react ion)
               2 6 . Ocular mot ilit y (A ssociat ed parallel movement s, nyst agmus)
               2 7 . Heart (Thrust , size, rhyt hm, sounds)
               2 8 . Lungs and chest (Include breast s)
               2 9 . V ascular syst em (V aricosit ies, et c.)
               3 0 . A nus and rect um (Hemorrhoids, Fist ulae) (Prost at e if indicat ed)
               3 1 . A bdomen a nd viscera (Include hernia)
               3 2 . Ext ernal genit alia (Genit ou rinary)
               3 3 . Upper ext remit ies
               3 4 . Low er ext remit ies (Except f eet )
               3 5 . Feet (See It em 3 5 Cont inued)

               3 6 . Spine, ot her m usculoskelet al
               3 7 . Ident if ying body marks, scars, t at t oos
               3 8 . Skin, lymphat ics
               3 9 . Neurologic
               4 0 . Psychiat ric (Specif y an y personalit y deviat ion )
               4 1 . Pelvic (Females only)
               4 2 . Endo crine                                                                                            3 5 . FEET (Cont inued) (Circle cat egory)
               4 3 . DENTAL DEFECTS AND DISEASE (Please explain. Use d ent al f orm if complet ed                                Normal A rch                         Mild                 A sympt omat ic
                                                by dent ist . If dent al examinat ion not done by
                      A ccept able              dent al of f icer, explain in It em 4 4 .)                                       Pes Cavus                            Moderat e                                         70
                      Not A ccept able Class                                                                                     Pes Planus                           Severe               Sympt omat ic

               DD FORM 2808 , JAN 2003                                              DoD except ion t o SF 88 approved by ICMR, A ugust 3, 2000.                                              Page 1 of 3 Pages
                                                                                              PREV IOUS EDITION IS OBSOLETE.
               LAST NAME - FIRST NAME - MIDDLE NAME (SUFFIX )                                                                                            SOCIAL SECURITY NUMBER


               LABORATORY FINDINGS
                                                                                  Joe, Gerold I.                                                           555-55-5555
               4 5 . URINALYSIS                          a. Albumin                           4 6 . URINE HCG                       4 7 . H/H                        4 8 . BLOOD TYPE
                                                         b. Sugar
               TESTS                                     RESULTS                                                           HIV SPECIMEN ID LA BEL                    DRUG TEST SPECIMEN ID LABEL


DD form 2808   4 9 . HIV
               5 0 . DRUGS
               5 1 . ALCOHOL


   Page 2      5 2 . OTHER
                 a. PA P SMEAR
                 b.
                 c.
                                                                                      MEASUR               R
                                                                                            EMENTS AND OTHE FINDINGS
               5 3 . HEIGHT       5 4 . WEIGHT           5 5 . MIN WGT - MAX WGT                              MAX BF %                      5 6 . TEMPERATURE             5 7 . PULSE
                                                  lbs.
               5 8 . BLOOD PRESSURE                                                           5 9 . RED/GREEN (A rmy Only)                  6 0 . OTHER V ISION TEST
               a. 1 ST            b. 2 ND                       c. 3 RD
               SYS.               SYS.                          SYS.
               DIA S.             DIA S.                        DIA S.
               6 1 . DISTANT V ISION                                      6 2 . REFRACTION BY AUTOREFRACTION OR MANIFEST                    6 3 . NEAR V ISION
               Right 2 0 /               Corr. t o 2 0 /                  By             S.              CX                                Right 2 0 /          Corr. t o 2 0 /         by
               Lef t 2 0 /         Corr. t o 2 0 /                        By             S.              CX                                Lef t 2 0 /          Corr. t o 2 0 /         by
               6 4 . HETEROPHORIA (Specif y dist ance)
               ES                 EX                       R.H.                   L.H.                        Prism div.            Prism Conv                              NPR               PD
                                                                                                                                    CT

               6 5 . ACCOMMODATION                                        6 6 . COLOR V ISION (Test used and result )               6 7 . DEPTH PERCEPTION (Test used and score) AFV T
               Right                     Lef t                            PIP                                      /1 4             Uncorrect ed                              Correct ed
               6 8 . FIELD OF V ISION                                                 6 9 . NIGHT VISION (Test used and score)                    7 0 . INTRAOCULAR TENSION
                                                                                                                                                  O.D.                        O.S.
               7 1 a. AUDIOMETER         Unit Serial Number                                      7 1 b. Unit Serial Number                                                    7 2 a. READING ALOUD
                                                                                                                                                                                     TEST
                      Dat e Calibrat ed (YYYY MMDD)                                              Dat e Calibrat ed (YYYY MMDD)
                       HZ       500        1000          2000     3000         4000      6000        HZ          500       1000    2000         3000     4000      6000              SA T         UNSA T
               Right                                                                             Right                                                                        7 2 b. V ALSALV A
               Lef t                                                                             Lef t                                                                               SA T         UNSA T
               7 3 . NOTES (Cont inued) AND SIGNIFICANT OR INTERV AL HISTORY (Use addit ional sheet s if necessary.)




                                                                                                                                                                                                            71

               DD FORM 2808 , JAN 2003                                                                                                                                                  Page 2 of 3 Pages
               LAST NAME - FIRST NAME - MIDDLE NAME (SUFFIX )                                                                           SOCIAL SECURITY NUMBER


               7 4 .a. EX AMINEE/APPLICANT (check one)
                                                                     Joe, Gerold I.            7 5 . I have been ad                        g
                                                                                                                                             555-55-5555
                                                                                                                   vised of my disqualifyin condition.
                      IS QUA LIFIED FOR SERV ICE                                                a. SIGNATURE OF EX AMINEE                                        b. DATE (YYYYMMDD)
                      IS NOT QUA LIFIED FOR SERV ICE
               b. PHYSICAL PROFILE

DD form 2808          P              U                 L             H               E               S                    X              PROFILER INITIA LS       DA TE (YYYY MMDD)




   Page 3
               7 6 . SIGNIFICANT OR DISQUALIFYING DEFECTS

               ITEM                                                       ICD       PROFILE       RBJ DA TE     QUA LI-        DIS-     EX A MINER            WA IV ER RECEIV ED
                            MEDICA L CONDITION/DIAGNOSIS                                                         FIED         QUA LI-
                NO.                                                      CODE       SERIA L     (YYYYMMDD)                     FIED      INITIA LS    SERV ICE       DA TE (YYYYMMD D)




               7 7 . SUMMARY OF DEFECTS AND DIAGNOSES (List diagnoses w it h it em numbers) (Use addit ional sheet s if necessary.)




               7 8 . RECOMMENDATIONS - FURTHER SPECIALIST EX AMINATIONS INDICATED (Specif y) (Use addit ional sheet s if necessary.)




               7 9 . MEPS WORKLOAD (For MEPS use only)
                          WKID                  ST             DA TE (YYYYMMDD)     INITIA L             WKID                           ST            DA TE (YYYYMMDD)          INITIA L




               8 0 . MEDICAL INSPECTION DATE           HT      WT        % BF   MA X WT     HCG       QUA L       DISQ                         PHYSICIA N' S SIGNA TURE




               8 1 .a. TYPED OR PRINTED NAME OF PHYSICIAN OR EX AMINER                              b. SIGNATURE


               8 2 .a. TYPED OR PRINTED NAME OF PHYSICIAN OR EX AMINER                              b. SIGNATURE


               8 3 .a. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN (Indicat e w hich)             b. SIGNATURE


               8 4 .a. TYPED OR PRINTED NAME OF REV IEWING OFFICER/APPROV ING AUTHORITY             b. SIGNATURE


               8 5 . This examination has been administratively reviewed for completeness and accuracy.
                a. SIGNATURE                                                                        b. GRADE                                 c. DATE (YYYY MMDD)


               8 6 . WAIV ER GRANTED (If yes, dat e and by w hom)                                                                                             8 7 . NUMBER OF
                      YES                                                                                                                                         ATTACHED SHEETS
                                                                                                                                                                                           72
                      NO
               DD FORM 2808 , JAN 2003                                                                                                                             Page 3 of 3 Pages
                                                                                                                                                                                                               Form A p proved
                                                                                        REPORT OF M EDICAL HISTORY
                                                                                                                                                                                                               OMB No. 0 7 0 4 -0 4 1 3
                                  (This information is for official and medically confidential use only and will not be released to unauthorized persons. )                                                    Expires A ug 3 1 , 2 0 0 3

                                  The public report ing burden f or t his collect ion of inf ormat ion is est imat ed t o average 10 minut es per response, including t he t ime f or reviewing inst ruct ions, searching exist ing data sources,
                                  gat hering and maint aining the dat a needed, and complet ing a               w
                                                                                                      nd revie ing t he collection of inf ormat ion. Send comment s regarding t his burden est imate or any ot her a     spect of t his collect ion
                                  of inf ormat ion, including suggest ions f or reducing t he burden, t o Depart ment of Def ense, Washingt on Headquart ers Services, Direct orat e f or Inf ormat ion Operat ions and Report s
                                  (0704-0413), 1215 Jef ferson Davis Highw ay, Suit e 1204, A rlingt on, V A 22202-4302. Respondent s should be aw are t hat not w it hst a             nding any ot her provision of law , no pe   rson shall be


   DD form 2807-1                 subject t o a                                                 ct
                                               ny penalty f or f ailing t o comply w ith a colle ion of inf ormat ion if it does not display a current ly valid OMB cont rol number.
                                  PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. RETUR COMPLE
                                                                                            N
                                                                             PRIVACY ACT STATEMENT
                                                                                                                       D
                                                                                                   TED FORM AS INDICATE ON PAGE 2 .

                                  AUTHORITY: 1 0 USC 5 0 4 , 5 0 5 , 5 0 7 , 5 3 2 , 9 7 8 , 1 2 0 1 , 1 2 0 2 , and 4 3 4 6 ; and E.O. 9 3 9 7 .


       Page 1
                                  PRINCIPAL PURPOSE(S): To obt ain medical dat a f or det erminat ion of medical f it ness f or e nlist ment , induct ion, appoint ment and ret ent ion f or applicant s and
                                  members of t he A rmed Forces. The inf ormat ion w ill als o be used f or med ical boards and s eparat ion of Serv ice members f rom t he A rmed Forces.
                                  ROUTINE USE(S): None.
                                  DISCLOSURE: V olunt ary; ho w ever, f ailure by an applica nt t o provide t he inf ormat io n may result i n delay or pos sible reject io n of t he indiv idual' s applic at ion t o ent er
                                  t he A rmed Forces. For an A rmed Forces memb er, f ailure t o provide t he inf ormat i on may resul t in t he ind ividual bein g placed in a non-deploy able st at us.
                                  WARNING: The inf ormat ion you have given const itut es an off icial st at ement . Federal law provides severe penalt ies (up t o 5 years conf ine-
                                  ment or a $ 1 0 , 0 0 0 f ine or bot h), t o anyone making a f alse st at ement . If you are select ed for enlist ment , commission, or ent rance int o a
                                  commissioning program based on a f alse st atement , you can be t ried by milit ary court s-mart ial or meet an administ rat ive board for discharge
                                  and could receive a less than honorable discharge t hat would af f ect your fut ure.
                                  1 . LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX )                                                  2 . SOCIAL SECURITY NUMBER                               3 . TODAY' S DATE (YYYYM MDD)

                                       Joe, Gerold I.
                                  4 .a. HOME ADDRESS (St reet , A part ment No., Cit y, St at e, and ZIP Code)
                                                                                                                                        555-55-5555
                                                                                                                                    5 . EX AMINING LOCATION AND ADDRESS (Include ZIP Code)
                                                                                                                                                                                                 01 JAN 04
                                        123 my street                                                                                   Madigan Army Medical Center
                                        Ft Lewis, WA 98433
                                   b. HOME TELEPHONE (Include A rea Code)

                                         (253) 555-4321                                                                                 Tacoma, WA 98431
                                  X ALL APPLICABLE BOXES:                                                                                                                                    7 .a. POSITION (Tit le, Grade, Component )
                                         R
                                  6.a. SE VICE            b. COMPONENT                                  c. PURPOSE OF EX AMINATION

                                    x      A rmy
                                                                Coast
                                                                Guard        x     A ct ive Dut y              Enlist ment
                                                                                                                                     x     Medical Board               Ot her (Specif y)       SGT,E-5,AD ARMY
                                           Navy
                                           Marine Corps
                                                                            xx     Reserve
                                                                                   Nat ional Guard
                                                                                                               Commission
                                                                                                               Ret ent ion
                                                                                                                                           Ret irement
                                                                                                                                           U.S. Service A cademy
                                                                                                                                                                                              b. USUAL OCCUPATION


                                           A ir Force
                                  8 . CURRENT MEDICATIONS (Prescript i on and Over- t he-count er)
                                                                                                               Separat ion                            Truck driver
                                                                                                                                           ROTC Sch olarship Program
                                                                                                                                    9 . A LLERGIES (Including insect bit es/st ings, f oods, medicine or ot her subst ance)


                                       Advil, Zomig, Vicodin                                                                         Penicillin, Bee Stings, Peanuts
                                  Mark each item "YES" or "NO".                   Every item marked "YE      t
                                                                                                       S" mus be fully explained in Item 29 on Page 2 .
                                  HAVE YOU EVER HAD OR DO YOU NOW HAVE:                                              YES NO              1 2 . (Cont inued)                                                                           YES NO
                                  1 0 .a. Tuberculosis
                                      b. Liv ed w it h some one w ho had t uberculosis                                         *             f.   Foot t rouble (e.g., pain, corns, bun ions, et c.)
                                                                                                                                             g. Impaired use of arms, legs, hands, or f eet                                                    *
                                      c. Coughed up blood                                                                      *             h.   Sw ollen o r painf ul joint (s)                                                              *
                                                                                                                                                                                                                                               *
                                      d. A st hma or any bre hing problems relat ed t o exe
                                             pollens, et c.
                                                            at                             rcise, w eat her,
                                                                                                                               *
                                                                                                                               *
                                                                                                                                             i.
                                                                                                                                             j.
                                                                                                                                                  K nee t rouble (e. g. , locking, giving out , pa or ligament injury, et c. )
                                                                                                                                                  A k e or foot s ge inc
                                                                                                                                                   ny ne
                                                                                                                                                                                                  in
                                                                                                                                                                 ur ry luding a
                                                                                                                                                                              rthros o or th us of a s ope
                                                                                                                                                                                    c py    e e       c
                                                                                                                                                                                                                                               *
                                      e. Short ness of breat h
                                      f . Bronchit is                                                                          *
                                                                                                                               *
                                                                                                                                             k.
                                                                                                                                                  t o any bone or joint
                                                                                                                                                  A ny need t o use correct ive devices such as prost het ic devices, knee
                                                                                                                                                   brace(s), back support (s), lif t s or ort hot ics, et c.                                   *
                                                                                                                                                                                                                                               *
                                                                                                                               *                                                                                                               *
                                      g.    Wheezi ng or p roblems w it h w heezing                                                          l.   Bone, j oint , or ot h er def ormit y


                                                                                                                                                                                                                                               *
                                      h. Been prescribe d or used an inhaler                                                                 m. Plat e(s), sc rew (s), rod(s) or pin(s) in any bone
                                      i.
                                      j.
                                            A chronic cough o r cough at night
                                            Sinusit is
                                                                                                                               *
                                                                                                                               *
                                                                                                                                             n. Bro ken bone(s) (cracked or f ract ured)

                                                                                                                                                                                                                                               *
                                                                                                                               *                                                                                                               *
                                                                                                                                         1 3 .a. Freque nt indige st ion or heart burn
                                      k. Hay f ever                                                                                          b. St oma ch, liver, in t est inal t rou ble, or ulcer
                                      l.    Chronic or f requent colds                                                  * *                  c. Gall b ladder t rouble or gallst ones                                                          *
                                                                                                                                                                                                                                               *
Note: Please insure that you
                                  1 1 .a. Severe t oot h or gum t rouble
                                      b. T hyroid t rouble o r goit er
                                                                                                                          *
                                                                                                                                             d. Jaundic e or hepat it is (liver disease)
                                                                                                                                             e. Rup t ure/hernia                                                                               *
mark ANY and ALL Medical
                                      c. Eye disorder or t rouble
                                      d. Ear, nose, or t hroat t rouble
                                                                                                                          *
                                                                                                                          *
                                                                                                                                             f.   Rect al disea se, hemorrhoids or b lood f rom t he rect um
                                                                                                                                             g. Skin diseases (e.g. acne, eczema, psoriasis, et c.)
                                                                                                                                                                                                                                               *
                                                                                                                                                                                                                                               *
conditions you have had during
                                      e. Loss of vision in eit her eye
                                      f.    Worn cont act lenses or glasses
                                                                                                                          *
                                                                                                                          *
                                                                                                                                             h. Fr equent or painf ul urinat ion
                                                                                                                                             i.   High or low blo od sugar
                                                                                                                                                                                                                                               *
                                                                                                                                                                                                                                               *
your military career. The             g. A h earing loss or w ear a hearing aid                                           *
                                                                                                                          *                  j.   Kidney st one o r blood in urine                                                             *
                                                                                                                                                                                                                                               *
Reviewing Physician will
                                      h. Surgery t o co rrect vision (RK, PRK, LA SIK, et c.)
                                                                                                                          *                   k. S ugar or prot ein in urine
                                                                                                                                              l. Sexually t ransmit t ed disease (syphilis, gonorrhea, chlamydia genit al
                                                                                                                                                                                                                ,                              *
                                                                                                                        * *                                                                                                                    *
                                  1 2 .a. Painf ul should er, elbow or w rist (e. g. pain, dislocat ion, et c. )                                                ,
                                                                                                                                                  warts, herpes etc.)


                                                                                                                                                                                                                                               *
                                      b. A rt hrit is, rheumat ism, or bursit is                                                         1 4 .a. A dverse react ion t o serum, f ood, insect st ings or medicine

determine if further evaluation       c. Rec urrent back pain or any back problem                                                            b. Recent u nexplained gain or los s of w eight


of the condition is required
                                      d. Numbne ss or t ingling
                                      e. Loss of f inger or t oe
                                                                                                                        * *                  c. Cur rent ly in g ood healt h (If no, explain in It em 2 9 on Page 2 .)
                                                                                                                                             d. Tumor, grow t h, cyst , or cancer
                                                                                                                                                                                                                                               *
                                                                                                                                                                                                                                               *
                                                                                                                                                                                                                                                      73

                                  DD FORM 2807 -1, JUL 2001                                                               *
                                                                                                                DoD except ion t o SF 93 approved by ICMR, A ugust 3, 2000.
                                                                                                         PREV IOUS EDITION MA Y BE USED UNTIL FEBRUA RY 1 , 2 0 0 2 .
                                                                                                                                                                                                                         Page 1 of 3 Pages
                                                                                                                                                                                                                                        U A AV
                                                                                                                                                                                                                                               *
                                                                                                                                                                                                                                         S P 1.00
                     LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX )                                                                           SOCIAL SECURITY NUMBER



                      Joe, Gerold I.                                                                                                           555-55-5555
  DD form 2807-1     Mark each item "YES" or "NO". Every item marked "YES" must be fully exp
                     HAVE YOU EVER HAD OR DO YOU NOW HAVE:                   YES NO
                                                                                            lained in Item 2 9 below.
                                                                                                                                                                                            YES NO


      Page 2
                     1 5 .a. Dizziness or f aint ing spells
                                                                                                           *   1 9 . Have you be en ref used employmen t or been unable t o hold a job
                                                                                                                     or st ay in school because of :
                         b. Frequent or severe headache
                         c. A he ad injury, memory loss or amnesia                                         *
                                                                                                           *
                                                                                                                    a. Sensit ivit y t o chemicals, dust , sunlight , et c.
                                                                                                                    b. Inabilit y t o per f orm cert ain mot ions                               *
                                                                                                           *                                                                                    *
                         d. Paralysis
                                                                                                                    c. Inabilit y t o st and, sit , kneel, lie dow n, et c.

                                                                                                           *                                                                                    *
                         e. Seizures , convulsions, e pilepsy or f it s
                         f.   Car, t rain, sea, or air sickness                                                     d. Ot her medical reasons (If yes, give reasons.)
                         g. A per iod of uncon sciousness o r concussion                                   *
                                                                                                           *   2 0 . Have you ever been t reat e d in an Emer gency Room?                       *
                         h. Me ningit is, encephal it is, or ot her neu rological problems
                                                                                                           *
                                                                                                                     (If yes, f or w hat ?)
                                                                                                                                                                                            *
                     1 6 .a. Rheumat ic f ever
                         b.
                         c.
                              Prolo nged bl eeding (as af t er an injury or toot h ext ract ion, et c. )
                              Pain or pr es s ure in t he c hes t
                                                                                                           *
                                                                                                           *
                                                                                                               2 1 . Have you ever been a pat ie nt in any t ype of hospit al? (If yes,
                                                                                                                     specif y w hen , w here, w hy, a nd name of doct or and complet e
                                                                                                                     address of hospit al.)
                                                                                                                                                                                                *
                         d. Palpi t at ion, pou nding heart or abnorma l heart beat                        *
                                                                                                           *   2 2 . Have you ev er had, or have you be en advised t o have any
                         e. Heart t rouble or murmur
                         f.   Hi gh or low bl ood pressure                                                 *         operat ion s or surgery? (If yes, describe and give age at w hich
                                                                                                                     occurred.)                                                                 *
                     1 7 .a. Nervous t rouble of any sort (anxiet y or panic at t acks)                    *
                                                                                                           *   2 3 . Have you ever h ad any illness or injury ot h er t han t hose
                         b. Habit ual st ammering or st ut t ering
                         c. Loss o f memory or amn esia, or neurol ogical sympt oms                        *
                                                                                                                     already not ed? (If yes, specif y w hen, w here, and give det ails.)
                                                                                                                                                                                                *
                                                                                                           *
                                                                                                               2 4 . Have you consult ed or been t reat ed by clinics, physicians,
                                                                                                                     healers, or ot her pract it io ners w it hin t he past 5 years f or
                         d. Fre quent t roub le sleeping
                                                                                                           *         ot her t han minor illnesses? (If yes, give complet e address
                                                                                                                     of doct or, hospit al, clini c, and det ails.)                             *
                         e. Received co unseling of any t ype
                         f . Depression or excessive w orry
                         g. Been evalu at ed or t reat ed f or a ment al condit ion
                                                                                                           *
                                                                                                           *   2 5 . Have you ever been reject ed f or milit ary service f or any

                         h.   A t t empt ed suicide                                                        *
                                                                                                           *
                                                                                                                     reason? (If yes, give dat e and reason f or reject ion.)
                                                                                                                                                                                                *
                         i.   Use d illegal d rugs or abu sed prescri pt ion drugs
                                                                                                           *   2 6 . Have you ever been discharged f rom milit ary service f or any
                                                                                                                     reason? (If yes, give dat e, reason, and t ype of discharge;
                     1 8 . FEMALES ONLY. H ave you e ver had or do you now have:
                          a. Treat ment f or a gynecologica l (f emale) disorder
                          b. A change of menst rual pat t ern                                              *
                                                                                                                     w het her h onorable, ot her t han hon orable, f or unf it ness or
                                                                                                                     unsuit abilit y.)                                                          *
                          c. A ny abn ormal PA P smears
                          d. First day of last menst rual period (YYYYM MDD)
                                                                                                           *
                                                                                                           *
                                                                                                               2 7 . Have you e ver received , is t here p ending, or h ave you ever
                                                                                                                     applie d f or pensio n or compens at ion f or an y disabilit y
                                                                                                                     or injury? (If yes, specif y w hat kind, grant ed by w hom,
                                                                                                                     and w h at amount , w hen, w hy.)                                          *
                         e. Dat e of last PA P smear (YYYY MMDD)


                          st at us.)
                                                                                                               2 8 . Have you ever been denied li f e insurance?
                     2 9 . EX PLANATION OF " YES" ANSWER(S) (Describe answ er(s), give d at e(s) of problem, name of doct or(s) and/or ho spit al(s), t reat ment gi ven and current medical    *

                                       10k, Seasonal allergies since I was 10 years old.
                                       (ongoing)
                                       12a,  Wrist pain is from lifting heavy rounds. Pain
Please Place                           started on 12Jun03 (Resolved)
“ongoing” or
“resolved” next to                     12c, Back pain started from lifting
each explanation.                      ammunition boxes into tanks. Pain is a 6 out of ten
                                       on most days (ongoing)                                                                                                                                           74
                                                      ,
                     NOTE: HAND TO THE DOCTOR OR NURSE OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL PERSONNEL ONLY. "
                     DD FORM 2807 -1, JUL 2001                                                                         Page 2 of 3 Pages
                                                                                                                                                                                             S P 1.00
                                                                                                                                                                                            U A AV
                     Standar d For m 507



       SF 507                                                                Report on
                         L IC L E O D
                        C IN A R C R                                                  or

extra room for more                                                          Continuation of S.F.
                                                                                                     (Strike out one line) (Specify type of examination or data)



  explanations of                                                                      (Sign and date)




    yes answers     16c, Chest pains come and go for
                      unknown reasons (ongoing)

                      20,  I was seen in the ER on 08OCT02 for a rash that
                      covered half my body from my waist down. It cleared
                      up two months later. (resolved)




                                                                                 (Continue on reverse side)

                      AT N 'S EN IF AT N
                     P IE T ID T IC IO     (For typed or written entries give: Name - last, first,                        E IS E O
                                                                                                                         R G T RN .                                 AR O
                                                                                                                                                                   W DN .
                                           middle; grade; date; hospital or medical facility)

                                                                                                         EOT N
                                                                                                        RP R O                           r OT U T N F
                                                                                                                                        o C N IN A IO O
                                                                                                                                        d    o
                                                                                                                                    Stan ardF rm507
                                                                                                                                    G N R L S R IC S A M IS A NA D
                                                                                                                                     E E A E V E D IN TR TIO N              75
                                                                                                                                      TE A E C O M        N E IC L E O D
                                                                                                                                    IN R G N Y C M ITTE O M D A R C R S
                                                                                                                                     P R 01-1
                                                                                                                                    FM 1      1-80-6-8
                                                                                                                                     C BR
                                                                                                                                    O TO E 1975
                                                                                                                                     S P C 1.00
                                                                                                                                    UA P V
                       LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX )                                                           SOCIAL SECURITY NUMBER


                                                                          Joe, Gerold I.                                          555-55-5555
DD form 2807-1         3 0 . EXAMINER'S SUMMAR AND EL
                             quest ions 10 - 29 . P
                                                        Y
                                                      hysician/ pract it ioner may develop by interview any addit ional medical hist ory deemed import ant , and record any
                             signif icant f indings here. )
                                                                   ABOR     ATION OF ALL PER  TINE NT DATA (Physician/ practit ioner shall comment on all posit ive answers in




    Page 3              a. COMMENTS




 Please DO NOT
 Write on this page.




                        b. TYPED OR PRINT ED NAME OF EX AMINER (Last , First , Middle Init ial)   c. SIGNATURE                                            d. DATE SIGNED
                                                                                                                                                             (YY YYMMDD)            76

                       DD FORM 2807 -1, JUL 2001                                                                                                             Page 3 of 3 Pages
                                                                                                                                                                         S P 1.00
                                                                                                                                                                        U A AV
E-mail Consent




                 77

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:159
posted:2/12/2011
language:English
pages:77