DA Form 2453-R "Statement of Health and Medical Examination"

What Is DA Form 2453-R?

This is a military form that was released by the U.S. Department of the Army (DA) on September 1, 1961. The form, often mistakenly referred to as the DD Form 2453-R, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

Form Details:

  • A 1-page document available for download in PDF;
  • The latest version available from the Army Publishing Directorate;
  • Editable, free, and easy to use;

Download an up-to-date fillable DA Form 2453-R down below in PDF format or browse hundreds of other DA Forms stored in our online database.

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Download DA Form 2453-R "Statement of Health and Medical Examination"

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STATEMENT OF HEALTH AND
For use of this form, see AR 145-1; the proponent agency is DCS, G-1.
MEDICAL EXAMINATION
SCHOOL
DATE
I underwent a medical examination in conjunction with enrollment in MS III on or about
at
,
(Date)
(Place)
and to the best of my knowledge and belief there has been no change in my medical condition since the
accomplishment of this medical examination except as noted below: (List changes in medical condition, or
insert "No change", as appropriate.)
(Signature)
APD LC v1.01ES
DA FORM 2453-R, 1 SEP 1961
STATEMENT OF HEALTH AND
For use of this form, see AR 145-1; the proponent agency is DCS, G-1.
MEDICAL EXAMINATION
SCHOOL
DATE
I underwent a medical examination in conjunction with enrollment in MS III on or about
at
,
(Date)
(Place)
and to the best of my knowledge and belief there has been no change in my medical condition since the
accomplishment of this medical examination except as noted below: (List changes in medical condition, or
insert "No change", as appropriate.)
(Signature)
APD LC v1.01ES
DA FORM 2453-R, 1 SEP 1961