DA Form 2453-R Statement of Health and Medical Examination

DA Form 2453-R or the "Statement Of Health And Medical Examination" is a Department of the Army-issued form used by and within the United States Military.

The form - often incorrectly referred to as the DD form 2453-R - was last revised on September 1, 1961. Download an up-to-date fillable DA Form 2453-R down below in PDF-format or look it up on the Army Publishing Directorate website.

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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

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

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