DD Form 2807-2 "Accessions Medical Prescreen Report"

What Is a DD Form 2807-2?

DD Form 2807-2, Accessions Medical Prescreen Report is a form that has to be completed by the person requiring medical processing within the DOD Instruction protocol. The pre-screening report is filled out by the recruiter and individual seeking to join the military and is part of a series of forms used for disclosing the medical information of the recruit.

The last valid edition of the form - sometimes confused with the DA Form 2807, Military Working Dog Training and Utilization Record - was released by the Department of Defense (DoD) in March 2015. An up-to-date fillable version of the DD 2807-2 is available for digital filing and download below or can be found on the Executive Services Directorate website.

The applicant should complete this form along with the recruiter, guardian, or parent - if needed. The DD Form 2807-2 provides a full health history of the individual. Positive responses to some questions do not automatically result in a disqualification but do require a full explanation. The form must be submitted at least 1 day in advance, and 2 days in advance if any support documentation is required.

The recruit will need to retrieve all medical documentation about past conditions, like broken limbs, surgeries etc. All documentation on any past or present treatments or consultation with a psychiatrist, psychologist, or therapist should also be attached to the report.

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DD Form 2807-2 Instructions

  1. Fill in the personal information in Section I: the name, age, date of birth, social security number, height, current and maximum weight, any previous military experience, the purpose of examination, current position and usual occupation. The applicant must also provide the date of filing the form.
  2. Section II contains questions about the medical history of the applicant. This section must be filled in completely. Each positive answer must be followed by a further explanation in Section III. All the additional information, such as the names of doctors, clinics, the dates and details of medical treatment must also be provided on the form.
  3. If you answered YES to any of the questions in the previous section, provide a full explanation of the situation: provide dates, names of health care providers, clinics or hospitals and their locations. List the procedures that were done to you and describe your current medical status.
  4. Attach extra sheets if necessary; sign and date each additional page. Obtain copies of applicable medical evaluation and treatment records to attach to the report.
  5. In Section IV, provide information on your current and previous healthcare providers and insurance carriers. Include their names, addresses, and phone numbers. Attach additional sheets, if necessary.
  6. Section V is reserved for validation of the applicant and the recruiter.
  7. In Section VI the medical provider to summarizes information on the applicant's data given above.
  8. Section VII is the last on the DD 2807-2 and contains the final determination of requestor's application.

DD 2807-2 Related Forms

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INSTRUCTIONS FOR COMPLETING DD FORM 2807-2,
ACCESSIONS MEDICAL PRESCREEN REPORT
1. This form is to be completed by each individual who requires medical processing in accordance with Department of Defense Instruction (DODI)
6130.03, “Physical Standards for Appointment, Enlistment, or Induction” and DODI 1304.02, “Accession Processing Data Collection Forms.” This
form must be completed by the applicant with the assistance of the recruiter, parent(s), or guardian, as needed.
2. Replaces the existing medical prescreen form (DD Form 2807-2, AUG 2011). Additional questions have been added to improve its usefulness to the
accessions medical pre-screening process. The questions are intended to provide the U.S. Military Entrance Processing Command (USMEPCOM) with
health history information necessary to identify conditions commonly related to medical causes for separation during basic and follow-on training (per
P.L. 105-85, Div. A, Title V, S 532).
3. Use of medical history information facilitates efficient, timely, and accurate medical processing of individuals applying for Service in the United
States Armed Forces or United States Coast Guard. Positive responses do not automatically result in disqualification but are necessary to prompt further
explanation that will be used to determine medical qualification. Medical history information assists USMEPCOM medical personnel in the medical
prescreening of applicants. Accurate responses to all questions are critical and all positive responses must be fully explained. Applicant responses to
questions may be verified using electronically obtained medical history by the USMEPCOM. Medical history information will be used by the
Department of Defense for continuity of care purposes if and when an applicant accesses into the Armed Forces or Coast Guard. Supporting medical
information in the form of historical medical records may also be attached to the Service member’s medical record. Medical history information
collected by the USMEPCOM during accession medical processing will serve as the foundation for a Service member’s lifecycle medical treatment
record.
4. The completed DD Form 2807-2 along with all substantiating and supporting medical documents must be delivered to USMEPCOM for review prior
to scheduling the applicant for medical examination. All documents must be submitted for review in accordance with standards below. After review, the
Military Entrance Processing Station (MEPS) will notify the Recruiting Service of the applicant’s status.
- 1 processing day prior for applicants with no positive medical history (all items marked “NO” with the exception of items 9 (glasses/contacts), 11
(defective color vision), and 20 (braces) which can be “YES”).
- 2 processing days prior; for applicants with ANY positive medical history (other than those noted above) and 5 OR LESS single-sided pages of
supporting medical documents.
- 3 processing days prior; for applicants with ANY positive medical history (other than those noted above) and MORE THAN 5 single-sided pages of
supporting medical documents.
Secure electronic submission is preferable; if not feasible bring/mail to the nearest MEPS which can be found at
http://www.mepcom.army.mil/
battalions/index.html. All supporting medical documentation must be present with the DD Form 2807-2 to meet the above timeframes for review. After
review by a USMEPCOM provider, appropriate processing notification will be made.
5. If an applicant has been seen by any Health Care Provider (HCP) and/or has been hospitalized for any reason, medical records/documentation must be
obtained and submitted along with a medical release to USMEPCOM. Provide all medical documents via secure electronic submission (if possible) to
the nearest MEPS. If hand-carried or mailed, ensure they are sealed in an envelope marked: “CONFIDENTIAL: MEPS MEDICAL DEPARTMENT".
a. If the applicant was evaluated and/or treated on an out-patient basis, obtain a copy of actual treatment records of the private medical doctor/HCP
including:
(1) office or clinic assessment and progress notes, including the initial assessment documents, subsequent evaluation and treatment documents, and
record of date when released from care to full, unrestricted activity;
(2) emergency room (ER) report(s);
(3) study reports (e.g. x-ray, magnetic resonance imaging (MRI), Computerized Tomography (CT), etc.);
(4) procedure reports (e.g., arthroscopy, electroencephalogram (EEG; brain wave test), echocardiogram (ultrasound of the heart), etc.);
(5) pathology reports (e.g., tissue specimens sent to lab for microscopic diagnosis, abnormal PAP smear cytology, etc.);
(6) specialty consultation records (e.g., neurologist, cardiologist, OB/GYN, gastroenterologist, orthopedic surgeon, pulmonologist, allergist, etc.).
b. If the applicant was hospitalized, obtain a copy of the inpatient hospital record, to include (if any): ER report, admission history and physical,
study reports, procedure reports, operative report (example: surgery to bone or joint), pathology report, specialty consultation reports, and discharge
summary.
c. If an applicant has been diagnosed or treated for any attention disorder (Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity
Disorder (ADHD), etc.), academic skills or perceptual defect, or had an Individualized Education Plan or 504 Plan, call/contact the MEPS medical
department for additional instructions.
d. Obtain any and all documents relating to any evaluation, treatment or consultation with a psychiatrist, psychologist counselor, or therapist, on an
inpatient or out-patient basis for any reason, including but not limited to counseling or treatment for adjustment or mood disorder, family or marriage
problems, depression, treatment or rehabilitation for alcohol, drug, or substance abuse.
6. MEPS Chief Medical Officers (CMOs) may locally modify the above instructions and instruct recruiters on what supporting medical documents they
require to complete the DD Form 2807-2 medical prescreen review, if doing so enhances the efficiency of medical processing and is consistent with
DODI 6130.03 and USMEPCOM guidance.
7. If all attempts to obtain required substantiating and supporting medical documents fail, the recruiter must contact the MEPS medical department for
guidance prior to submitting an incomplete medical prescreen packet.
DD FORM 2807-2, MAR 2015
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 7 Pages
Adobe Designer 9.0
INSTRUCTIONS FOR COMPLETING DD FORM 2807-2,
ACCESSIONS MEDICAL PRESCREEN REPORT
1. This form is to be completed by each individual who requires medical processing in accordance with Department of Defense Instruction (DODI)
6130.03, “Physical Standards for Appointment, Enlistment, or Induction” and DODI 1304.02, “Accession Processing Data Collection Forms.” This
form must be completed by the applicant with the assistance of the recruiter, parent(s), or guardian, as needed.
2. Replaces the existing medical prescreen form (DD Form 2807-2, AUG 2011). Additional questions have been added to improve its usefulness to the
accessions medical pre-screening process. The questions are intended to provide the U.S. Military Entrance Processing Command (USMEPCOM) with
health history information necessary to identify conditions commonly related to medical causes for separation during basic and follow-on training (per
P.L. 105-85, Div. A, Title V, S 532).
3. Use of medical history information facilitates efficient, timely, and accurate medical processing of individuals applying for Service in the United
States Armed Forces or United States Coast Guard. Positive responses do not automatically result in disqualification but are necessary to prompt further
explanation that will be used to determine medical qualification. Medical history information assists USMEPCOM medical personnel in the medical
prescreening of applicants. Accurate responses to all questions are critical and all positive responses must be fully explained. Applicant responses to
questions may be verified using electronically obtained medical history by the USMEPCOM. Medical history information will be used by the
Department of Defense for continuity of care purposes if and when an applicant accesses into the Armed Forces or Coast Guard. Supporting medical
information in the form of historical medical records may also be attached to the Service member’s medical record. Medical history information
collected by the USMEPCOM during accession medical processing will serve as the foundation for a Service member’s lifecycle medical treatment
record.
4. The completed DD Form 2807-2 along with all substantiating and supporting medical documents must be delivered to USMEPCOM for review prior
to scheduling the applicant for medical examination. All documents must be submitted for review in accordance with standards below. After review, the
Military Entrance Processing Station (MEPS) will notify the Recruiting Service of the applicant’s status.
- 1 processing day prior for applicants with no positive medical history (all items marked “NO” with the exception of items 9 (glasses/contacts), 11
(defective color vision), and 20 (braces) which can be “YES”).
- 2 processing days prior; for applicants with ANY positive medical history (other than those noted above) and 5 OR LESS single-sided pages of
supporting medical documents.
- 3 processing days prior; for applicants with ANY positive medical history (other than those noted above) and MORE THAN 5 single-sided pages of
supporting medical documents.
Secure electronic submission is preferable; if not feasible bring/mail to the nearest MEPS which can be found at
http://www.mepcom.army.mil/
battalions/index.html. All supporting medical documentation must be present with the DD Form 2807-2 to meet the above timeframes for review. After
review by a USMEPCOM provider, appropriate processing notification will be made.
5. If an applicant has been seen by any Health Care Provider (HCP) and/or has been hospitalized for any reason, medical records/documentation must be
obtained and submitted along with a medical release to USMEPCOM. Provide all medical documents via secure electronic submission (if possible) to
the nearest MEPS. If hand-carried or mailed, ensure they are sealed in an envelope marked: “CONFIDENTIAL: MEPS MEDICAL DEPARTMENT".
a. If the applicant was evaluated and/or treated on an out-patient basis, obtain a copy of actual treatment records of the private medical doctor/HCP
including:
(1) office or clinic assessment and progress notes, including the initial assessment documents, subsequent evaluation and treatment documents, and
record of date when released from care to full, unrestricted activity;
(2) emergency room (ER) report(s);
(3) study reports (e.g. x-ray, magnetic resonance imaging (MRI), Computerized Tomography (CT), etc.);
(4) procedure reports (e.g., arthroscopy, electroencephalogram (EEG; brain wave test), echocardiogram (ultrasound of the heart), etc.);
(5) pathology reports (e.g., tissue specimens sent to lab for microscopic diagnosis, abnormal PAP smear cytology, etc.);
(6) specialty consultation records (e.g., neurologist, cardiologist, OB/GYN, gastroenterologist, orthopedic surgeon, pulmonologist, allergist, etc.).
b. If the applicant was hospitalized, obtain a copy of the inpatient hospital record, to include (if any): ER report, admission history and physical,
study reports, procedure reports, operative report (example: surgery to bone or joint), pathology report, specialty consultation reports, and discharge
summary.
c. If an applicant has been diagnosed or treated for any attention disorder (Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity
Disorder (ADHD), etc.), academic skills or perceptual defect, or had an Individualized Education Plan or 504 Plan, call/contact the MEPS medical
department for additional instructions.
d. Obtain any and all documents relating to any evaluation, treatment or consultation with a psychiatrist, psychologist counselor, or therapist, on an
inpatient or out-patient basis for any reason, including but not limited to counseling or treatment for adjustment or mood disorder, family or marriage
problems, depression, treatment or rehabilitation for alcohol, drug, or substance abuse.
6. MEPS Chief Medical Officers (CMOs) may locally modify the above instructions and instruct recruiters on what supporting medical documents they
require to complete the DD Form 2807-2 medical prescreen review, if doing so enhances the efficiency of medical processing and is consistent with
DODI 6130.03 and USMEPCOM guidance.
7. If all attempts to obtain required substantiating and supporting medical documents fail, the recruiter must contact the MEPS medical department for
guidance prior to submitting an incomplete medical prescreen packet.
DD FORM 2807-2, MAR 2015
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 7 Pages
Adobe Designer 9.0
OMB No. 0704-0413
ACCESSIONS MEDICAL PRESCREEN REPORT
OMB approval expires
Oct 31, 2017
The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100
(0704-0413). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS.
currently valid OMB control number.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 504, 505, 507, 532, 978, 1201, 1202, and 4346; and E.O. 9397 (SSN).
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): DoD Blanket Routine Uses found at
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx
apply to the use of this
data.
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.
WARNING: The information you have given constitutes an official statement. Federal law provides severe penalties (up to 5 years confinement or $10,000
fine, or both), to anyone making a false statement. If you are selected for enlistment, commission or entrance into a commissioning program based on a
false statement, you may be subject to prosecution under the Uniform Code of Military Justice or to administrative separation proceedings for discharge, and
could receive a less than honorable discharge.”
SECTION I - APPLICANT
1. LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)
2. AGE
3. DATE OF BIRTH (YYYYMMDD)
4. SOCIAL SECURITY NUMBER
7. MAX WEIGHT
5. HEIGHT (inches)
6. WEIGHT (lbs.)
8. SERVICE AND COMPONENT (X as applicable)
9. DATE (YYYYMMDD)
(lbs.)
Army
USMC
Regular
Navy
USCG
Reserve Component
USAF
Other:
National Guard
11. POSITION (If a current Federal Employee)
10. PURPOSE OF EXAMINATION (X as applicable)
12. USUAL OCCUPATION
(Job Title, Grade, Component)
Enlistment
U.S. Service Academy
Commission
ROTC Scholarship
Retention
Other (Specify)
SECTION II - MEDICAL HISTORY.
Initial each item "Yes" or "No". All "Yes" items must be fully explained in Section III (Pages 4 and 5).
CURRENTLY HAVE OR ANY HISTORY OF:
CURRENTLY HAVE OR ANY HISTORY OF:
YES
NO
YES
NO
EYES
LUNGS, CHEST WALL, PLEURA, AND MEDIASTINUM
1. Double vision
22. Asthma
2. Detached retina or surgery to repair a detached retina
23. Wheezing
3. Cataracts or surgery for cataracts
24. Shortness of breath
4. Eye surgery to improve vision (RK, PRK, LASIK, etc.)
25. Bronchitis
26. Other breathing problems worsened by exercise, weather,
5. Night blindness
pollens, etc.
6. Glaucoma
27. Used inhaler(s) or steroids for breathing problem(s)
7. Strabismus or "lazy eye" or any surgery to correct these
28. Chronic cough or frequent coughing at night
8. Any other eye condition, injury or surgery
29. Collapsed lung or other lung condition
VISION
30. History of chest, chest wall, or breast surgery
9. Worn/wear contact lenses or glasses (Bring your contact lens kit
HEART
and solution so you can remove contacts during vision testing, or
for best results remove 72 hours prior. Bring your eyeglasses no
31. Heart murmur, valve problem or mitral valve prolapse
matter how old they are.)
32. Palpitation, pounding heart or abnormal heartbeat
10. Loss of vision in either eye
33. Heart surgery
11. Color vision deficiency or color blindness
34. Pain or pressure in the chest
EARS
35. An abnormal electrocardiogram (EKG)
12. Perforated ear drum or tubes in ear drum(s)
36. Any other heart problems
13. Ear surgery, to include mastoidectomy or repair of perforated
ABDOMINAL ORGANS AND GASTROINTESTINAL SYSTEM
ear drum
14. Loss of balance or vertigo
37. Stomach, esophageal or intestinal ulcer
HEARING
38. Difficulty swallowing
15. Hearing loss or wear a hearing aid
39. Frequent indigestion or heartburn
NOSE, SINUSES, MOUTH, AND LARYNX
40. Gall bladder trouble or gallstones
16. Ear, nose, or throat trouble including tonsillectomy
41. Jaundice (except neonatal) or hepatitis (liver disease)
17. Chronic sinus infections or recurrent nose bleeds
42. Rupture/hernia
43. Surgery to remove or repair a portion of the intestine or spleen
18. Absence of, or disturbance of sense of smell
(other than the appendix)
19. Any surgery of your face, mandible or jaw
44. Chronic or recurrent intestinal problem of the small or large
DENTAL
bowel such as Irritable Bowel Syndrome, Crohn's disease,
20. Do you wear dental braces or plan to wear braces? (If so, your
Ulcerative Colitis, or Celiac disease
orthodontist must submit a letter stating that active orthodontic
45. Rectal disease, hemorrhoids, or blood from the rectum
treatment will be completed prior to active duty date: release form/
sample format can be found in the Recruiter's Medical Guide.)
46. Hemorrhoid surgery
21. Tooth or gum problems (other than cavities)
47. Bariatric surgery (weight loss surgery)
DD FORM 2807-2, MAR 2015
Page 2 of 7 Pages
LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)
SOCIAL SECURITY NUMBER (Last 4)
SECTION II - MEDICAL HISTORY
(Continued). Initial each item "Yes" or "No". All "Yes" items must be fully explained in Section III.
CURRENTLY HAVE OR ANY HISTORY OF:
YES
NO
CURRENTLY HAVE OR ANY HISTORY OF:
YES
NO
FEMALES ONLY:
SKIN AND CELLULAR
48. A change of menstrual pattern (other than pregnancy)
93. Acne or psoriasis
49. Pregnancy, abortion or miscarriage
94. Eczema
50. Any abnormal PAP smear(s)
95. Atopic dermatitis
51. Date of last PAP smear (YYYYMMDD)
96. Large or painful scars
52. Diagnosed with endometriosis or ovarian cysts
97. Any other skin problems
53. Evaluation, treatment or surgery for any other gynecological
BLOOD AND BLOOD FORMING TISSUES
(female) disorder
98. Anemia
54. Sexually transmitted disease (syphilis, gonorrhea, chlamydia,
99. Blood clots requiring blood thinner medicine
genital warts, herpes, etc.)
55. First day of last menstrual period (YYYYMMDD)
100. Absence or removal of the spleen
MALES ONLY:
101. Prolonged bleeding (after an injury or tooth extraction)
56. Missing a testicle, testicular implant, or undescended testicle
102. Any other blood or circulation problems
57. Variocele, hydrocele, or any scrotal mass, swelling or pain
SYSTEMIC
58. Prostate problems
103. Adverse reaction to medication (describe reaction in Section III)
59. Sexually transmitted disease (syphilis, gonorrhea, chlamydia,
104. Adverse reaction to serum, insect stings, or tree nuts
genital warts, herpes, etc.)
105. Allergy to common foods (milk, eggs, fish, meat, etc.)
URINARY SYSTEM
106. Allergy to wool, latex, or other material
60. Missing a kidney
107. Tuberculosis or lived with someone who had tuberculosis
61. Kidney stone, infection or disease
108. Positive test for tuberculosis (PPD or blood test)
62. Kidney or urinary tract surgery of any kind
109. Malaria
63. Blood or protein in urine
110. Disorder(s) of your immune system (including HIV)
64. Painful or difficult urination
111. Car, train, sea, or air sickness
65. Bedwetting or treatment for bedwetting (after childhood)
ENDOCRINE AND METABOLIC
66. Hernia
112. Thyroid trouble or goiter
SPINE AND SACROILIAC JOINTS
113. High or low blood sugar
67. Recurrent back pain or back problem
114. Diabetes or told that you should be tested for diabetes
68. Herniated disk
NEUROLOGIC
69. Recurrent neck pain
115. Cerebrovascular incident (stroke)
70. Back or neck surgery
116. Frequent or severe headaches, including migraines
71. Abnormal curvature of your spine (any part)
117. Taking medication to prevent headaches
UPPER EXTREMITIES
118. Lost time from work or school due to frequent or severe
72. Painful shoulder, elbow, wrist, hand or fingers
headaches
73. Dislocated shoulder, elbow, wrist, hand or fingers
119. A skull fracture
LOWER EXTREMITIES
120. A head injury, memory loss, or amnesia
74. Foot trouble (e.g., pain, corns, bunions, warts, ingrown toenails,
121. A period of unconsciousness or concussion
etc.)
122. Loss of memory or amnesia, or neurological symptoms
75. Knee trouble (e.g., locking, giving out, or ligament injury, etc.)
123. Paralysis
76. Painful hip, knee, ankle, foot or toes
124. Meningitis, encephalitis, or other neurological problems
77. Dislocated hip, knee, ankle, foot or toes
125. Seizures, convulsions, epilepsy or fits
MISCELLANEOUS CONDITIONS OF THE EXTREMITIES
126. Dizziness or fainting spells
78. Bone, joint, or other orthopedic deformity
127. Any other neurologic problems
79. Loss of finger or toe, or extra finger or toe
SLEEP DISORDERS
80. Loss of the ability to fully flex (bend) or fully extend a finger, toe,
128. Sleepwalking or narcolepsy
or other joint
81. Impaired use of arms, hands, legs, or feet (any reason)
129. Frequent trouble sleeping
82. Arthritis, rheumatism, or bursitis
130. Sleep apnea or severe snoring
83. Any swollen joint(s)
LEARNING, PSYCHIATRIC, AND BEHAVIORAL
131. Evaluated or treated for Attention Deficit Disorder (ADD) or
84. Surgery on any joint/bone (including arthroscopy)
Attention Deficit Hyperactivity Disorder (ADHD)
85. Plate(s), screw(s), rod(s) or pin(s) in any bone
132. Taken (or taking) medication, drugs, or any substance to
86. Pain or swelling at the site of an old fracture
improve attention, behavior, or physical performance
133. Diagnosed with a learning disorder, to include dyslexia
87. Any need to use corrective devices such as prosthetic devices,
knee brace(s), back support(s), lifts or orthotics
134. Received counseling of any type
88. Any other orthopedic, muscle, or sports injury problems
135. Seen a psychiatrist, psychologist, social worker, counselor or
other professional for any reason (inpatient or out-patient)
VASCULAR
including counseling or treatment for school, adjustment, family,
89. High or low blood pressure
marriage, divorce, depression, anxiety, or treatment of alcohol,
drug or substance abuse (Applicant or recruiter will request
90. Raynaud's phenomenon or disease
sealed medical supporting documents from health care pro-
91. Deep Vein Thrombosis (blood clot; leg or elsewhere)
viders marked "CONFIDENTIAL: MEPS MEDICAL DEPART-
MENT" and submit directly to MEPS medical personnel.)
92. Pulmonary embolism (blood clot in lung)
DD FORM 2807-2, MAR 2015
Page 3 of 7 Pages
LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)
SOCIAL SECURITY NUMBER (Last 4)
SECTION II - MEDICAL HISTORY
(Continued). Initial each item "Yes" or "No". All "Yes" items must be fully explained in Section III.
CURRENTLY HAVE OR ANY HISTORY OF:
YES
NO
CURRENTLY HAVE OR ANY HISTORY OF:
YES
NO
LEARNING, PSYCHIATRIC, AND BEHAVIORAL (Continued)
SUPPLEMENTAL QUESTIONS (Continued)
136. Been expelled or suspended from school
154. Any recent unexplained gain or loss of weight
155. Artificial or replacement body part (eye, bone, palate, hip, knee,
137. Been kicked out or removed from your home
joint, leg, arm, etc.)
138. Been arrested or other encounters with law enforcement
156. Have you ever had any illness or injury other than those already
139. Been evaluated or treated, either with medication or counseling,
noted? (If "yes", specify when, where and give details in
for a mental condition, depression or excessive worry
Section III.)
157. Have you ever been treated in an Emergency Room? (If "yes",
140. Nervous trouble of any sort (anxiety or panic attacks)
explain in Section III.)
141. Anorexia, bulimia, or other eating disorder
158. Have you ever been a patient in any type of hospital (including
142. Habitual stammering or stuttering
being kept overnight)? (If "yes", specify when, where, why, and
name of doctor and complete address of hospital in Section III.)
143. Have you ever purposely cut or harmed yourself
159. Have you ever had, or have you been advised to have any
144. Have you ever attempted or considered suicide
operations or surgery? (If "yes", describe and give age at which
145. Used illegal drugs or abused prescription drugs
occurred in Section III.)
160. Have you ever been rejected for military Service for any
146. Have you been evaluated, treated, or hospitalized for substance
reason? (If "yes", give date and reason in Section III.)
abuse, addiction or dependence (including illegal drugs,
prescription medications or other substances)
161. Have you ever been discharged from the military Service for
any reason? (If "yes", give date, reason, and type of discharge,
147. Have you been evaluated, treated, or hospitalized for alcohol
whether honorable, other than honorable, for unfitness or
abuse, dependence, or addiction
unsuitability in Section III.)
148. Post-traumatic Stress Disorder or excessive stress requiring
162. Have you ever been refused employment or been unable to
counseling and/or medication following a traumatic experience
hold a job or stay in school because of any of the following:
149. Any other learning, psychiatric, or behavioral problems
(If "yes", answer a - d below and give reasons in Section III.)
TUMORS AND MALIGNANCIES
a. Sensitivity to chemicals, dust, sunlight, etc.
150. Tumor, growth, cyst, or cancer of any type
b. Inability to perform certain motions
MISCELLANEOUS
c. Inability to stand, sit, kneel, lie down, etc.
151. Cold injury, frostbite or cold intolerance
d. Other medical reasons
152. Heat injury, heat stroke or heat intolerance
163. Applied for and/or received disability evaluation and/or
SUPPLEMENTAL QUESTIONS
compensation for an injury or other medical conditions
(If "yes", provide details in Section III.)
153. Are you taking any medications, to include over the counter
medications (OTCs), vitamin, herbal, or nutritional supplements
164. Have you ever been denied life insurance? (If "yes", provide
(If "yes", list all in Section III.)
reason(s) in Section III.)
SECTION III - APPLICANT COMMENTS.
Explain all "Yes" answers to questions 1 - 164 above.
Begin with the Item Number. Describe answer(s) fully: provide date(s) of problem(s)/condition(s); provide names of Health Care Providers (HCPs),
Clinic(s) and/or Hospital(s) along with the City and State; explain what was done (e.g., evaluation and/or treatment); and describe your current
medical status. Attach additional sheet(s) if necessary and sign and date each additional page. Obtain and attach copies of applicable medical
evaluation and treatment records.
DD FORM 2807-2, MAR 2015
Page 4 of 7 Pages
LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)
SOCIAL SECURITY NUMBER (Last 4)
SECTION III - APPLICANT COMMENTS
(Continued).
SECTION IV - HEALTH CARE PROVIDER/INSURANCE CARRIER CONTACT INFORMATION:
Current Primary Care Physician(s)/Practitioner(s) and/or Clinic(s) where care is received and Current/Previous Insurance Carrier(s) information.
Attach additional sheets if necessary.
1. CURRENT PRIMARY CARE PHYSICIAN(S)/PRACTITIONER(S) AND/OR CLINIC(S)
a. NAME(S)
b. ADDRESS (Include ZIP Code)
c. TELEPHONE (Include Area Code)
2. PREVIOUS PRIMARY CARE PHYSICIAN(S)/PRACTITIONER(S) AND/OR CLINIC(S)
a. NAME(S)
b. ADDRESS (Include ZIP Code)
c. TELEPHONE (Include Area Code)
3. CURRENT INSURANCE AND/OR PHARMACY BENEFIT MANAGER(S)
a. NAME(S)
b. ADDRESS (Include ZIP Code)
c. TELEPHONE (Include Area Code)
4. PREVIOUS INSURANCE AND/OR PHARMACY BENEFIT MANAGER(S)
a. NAME(S)
b. ADDRESS (Include ZIP Code)
c. TELEPHONE (Include Area Code)
DD FORM 2807-2, MAR 2015
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