DD Form 2492 DoD Medical Examination Review Board (Dodmerb) Report of Medical History

What Is DD Form 2492?

DD Form 2492, DoDMERB Report of Medical History is a form used to update a medical file of Coast Guard Academy and Merchant Marine Academy applicants and for determining the applicant's medical acceptability. The form is used when applying for the Reserve Officer Training Corps (ROTC) Scholarship Program, a United States Service Academy, or the Uniformed Services University of the Health Sciences (USUHS).

The form is sometimes incorrectly referred to as the DA Form 2492 and was released by the Department of Defense (DoD) in March 2008 with all previous editions obsolete. An up-to-date DD Form 2492 fillable version is available for digital filing and download below or can be found through the Executive Services Directorate website.

The DD 2492 is used strictly within the DoD as a replacement for the General Services Administration-approved SF Form 93, Report of Medical History. Completing the report is voluntary. However, failure to provide the necessary information may hamper the applicant's candidacy and negatively impact their chances of qualifying for the selected program.

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DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)
OMB No. 0704-0396
REPORT OF MEDICAL HISTORY
OMB approval expires
Nov 30, 2009
(This information is for official and medically confidential use only and will not be released to unauthorized persons.)
The public reporting burden for this collection of information is estimated to average 15 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, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon, Washington, DC 20301-1155
(0704-0396). 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 currently valid OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO DODMERB/DR, 8034
EDGERTON DRIVE, SUITE 132, USAF ACADEMY CO 80840-2200.
PRIVACY ACT STATEMENT
AUTHORITY: Title 10, USC 133, 3012, 5031, 8013, and Executive Order 9397.
PRINCIPAL PURPOSE: To determine medical acceptability or update a medical file as part of the application process to a United States Service Academy,
Reserve Officer Training Corps (ROTC) Scholarship Program, or the Uniformed Services University of the Health Sciences (USUHS).
ROUTINE USES: This information may be disclosed to the Coast Guard Academy and Merchant Marine Academy for applications to their Academies.
DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection process and hamper your candidacy. Use of the Social
Security Number (SSN) is used for positive identification of records.
1. NAME (Last, First, Middle Initial)
2. SOCIAL SECURITY NUMBER
3. TELEPHONE NO. (Include area code)
4. PURPOSE OF EXAMINATION
5. EXAMINATION FACILITY OR EXAMINER AND ADDRESS (Include ZIP Code)
6. DATE OF EXAMINATION
(YYYYMMDD)
Mark each item "Yes" or "No". EVERY QUESTION MUST BE ANSWERED, OR PROCESSING DELAYS WILL OCCUR.
Every "Yes" must be
explained in Block 83, REMARKS, on the back of the form. Mark and explain each item to the best of your ability. Be perfectly honest! Your medical records may be
requested to clarify your medical history.
7. HAVE YOU EVER OR DO
DO YOU
YES
NO
YES
NO
9a. If you wear contact lenses, how many days have they
YOU NOW USE ANY OF
been removed prior to this examination?
THE FOLLOWING:
Marijuana
8. Wear glasses
YES
NO
9. Wear contact lenses or
Alcohol (Amount,
Amphetamines
Less than 3
3 - 20
21 or over
frequency, treatment,
corneal eye retainers
if any)
Barbiturates
Type lens:
Hard
Soft
(If Yes, complete 9a.)
Cocaine
Chemical Inhalants
10. HAVE YOU EVER HAD YOUR VISION IMPROVED BY METHODS OTHER THAN STATED IN
QUESTIONS 8 OR 9?
Narcotic Drugs
Hallucinogens
YES
NO
HAVE YOU EVER HAD OR DO YOU NOW HAVE:
YES
NO
YES
NO
11. Eye trouble (exclude glasses, contact lenses)
40. Gallbladder trouble or gallstones
66. Sleepwalking episodes after age 12
12. Have fluctuating vision or double vision
41. Hepatitis (yellow jaundice)
67. Easily fatigued
13. Have any allergies
42. Hemorrhoids or rectal disease
68. Motion sickness (car, train, sea, or air)
14. Take any medications regularly
43. Black or bloody stools
69. X-ray or other radiation therapy
15. Stutter or stammer
44. Frequent or painful urination
70. Sensitivity to chemicals, dust, sunlight, etc.
16. Frequent, severe, or migraine headaches
45. Bed wetting after age 12
71. Learning disabilities or speech problems
HAVE YOU EVER
17. Fainting or dizzy spells
46. Blood, protein, or sugar in urine
YES
NO
18. Periods of unconsciousness
47. History of diabetes
72. Been refused employment or been unable to
hold a job or stay in school because of:
19. Head injury or skull fracture
48. Kidney stone
20. Epilepsy, seizures or convulsions
49. Hernia or rupture
a. Inability to perform certain movements?
21. Loss of memory (amnesia)
50. Any bone or joint problem, injuries, surgery
b. Inability to assume certain positions?
or medical treatment
22. Depression, anxiety, excessive worry, or
c. Other medical reasons?
nervousness
73. Been rejected for or discharged from military
51. Steel pins, plates, or staples in any bones
service because of physical, mental or other
23. Any mental condition or illness
52. Wear a bone or joint brace or support
reasons?
74. Been denied or rated up for life insurance?
24. Frequent trouble sleeping
53. Back pain or trouble
25. Hearing loss
54. Paralysis or weakness
75. Received or applied for pension or
compensation for existing disability?
26. Ear, nose, or throat trouble
55. Foot trouble/use orthotics
27. Sinusitis or sinus trouble
56. Rheumatic fever
76. Had or been advised to have, any surgical
operations?
28. Hay fever or allergic rhinitis
57. Tuberculosis or positive TB test
77. Consulted, or been treated by clinics,
29. Tooth/gum trouble, or current orthodontics
58. Sexually transmitted disease (syphilis,
hospitals, physicians, healers, or other
gonorrhea, herpes)
30. Thyroid trouble
practitioners for other than minor illnesses?
31. Chronic cough or lung disease
59. Skin conditions such as acne, psoriasis,
78. Had any injury or illness other than those
already noted?
hand or foot rashes, eczema, or dry skin
32. Asthma or wheezing
FEMALES ONLY
YES
NO
33. Unusual shortness of breath
(Complete Items 79 - 82)
60. Adverse reaction to vaccines, drugs,
medicines, foods, insect bites or stings
34. Pain or pressure in chest
79. Been treated for a female disorder, painful
periods, or cramps
35. Palpitation or pounding heart
61. Eating disorder
36. Heart trouble or heart murmur
62. Recent gain or loss of weight
80. Had a change in menstrual pattern
37. High blood pressure
63. Excessive bleeding or easy bruising
81. Are you now pregnant?
82. Date of last menstrual period (YYYYMMDD)
38. Coughed up or vomited blood
64. Tumor, growth, cyst, or cancer
39. Stomach, liver, or intestinal trouble
65. Considered or attempted suicide
DD FORM 2492, MAR 2008
PREVIOUS EDITION IS OBSOLETE.
DoD Exception to SF93 approved by GSA/IRMS (8-91)
Adobe Professional 7.0
Reset
DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)
OMB No. 0704-0396
REPORT OF MEDICAL HISTORY
OMB approval expires
Nov 30, 2009
(This information is for official and medically confidential use only and will not be released to unauthorized persons.)
The public reporting burden for this collection of information is estimated to average 15 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, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon, Washington, DC 20301-1155
(0704-0396). 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 currently valid OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO DODMERB/DR, 8034
EDGERTON DRIVE, SUITE 132, USAF ACADEMY CO 80840-2200.
PRIVACY ACT STATEMENT
AUTHORITY: Title 10, USC 133, 3012, 5031, 8013, and Executive Order 9397.
PRINCIPAL PURPOSE: To determine medical acceptability or update a medical file as part of the application process to a United States Service Academy,
Reserve Officer Training Corps (ROTC) Scholarship Program, or the Uniformed Services University of the Health Sciences (USUHS).
ROUTINE USES: This information may be disclosed to the Coast Guard Academy and Merchant Marine Academy for applications to their Academies.
DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection process and hamper your candidacy. Use of the Social
Security Number (SSN) is used for positive identification of records.
1. NAME (Last, First, Middle Initial)
2. SOCIAL SECURITY NUMBER
3. TELEPHONE NO. (Include area code)
4. PURPOSE OF EXAMINATION
5. EXAMINATION FACILITY OR EXAMINER AND ADDRESS (Include ZIP Code)
6. DATE OF EXAMINATION
(YYYYMMDD)
Mark each item "Yes" or "No". EVERY QUESTION MUST BE ANSWERED, OR PROCESSING DELAYS WILL OCCUR.
Every "Yes" must be
explained in Block 83, REMARKS, on the back of the form. Mark and explain each item to the best of your ability. Be perfectly honest! Your medical records may be
requested to clarify your medical history.
7. HAVE YOU EVER OR DO
DO YOU
YES
NO
YES
NO
9a. If you wear contact lenses, how many days have they
YOU NOW USE ANY OF
been removed prior to this examination?
THE FOLLOWING:
Marijuana
8. Wear glasses
YES
NO
9. Wear contact lenses or
Alcohol (Amount,
Amphetamines
Less than 3
3 - 20
21 or over
frequency, treatment,
corneal eye retainers
if any)
Barbiturates
Type lens:
Hard
Soft
(If Yes, complete 9a.)
Cocaine
Chemical Inhalants
10. HAVE YOU EVER HAD YOUR VISION IMPROVED BY METHODS OTHER THAN STATED IN
QUESTIONS 8 OR 9?
Narcotic Drugs
Hallucinogens
YES
NO
HAVE YOU EVER HAD OR DO YOU NOW HAVE:
YES
NO
YES
NO
11. Eye trouble (exclude glasses, contact lenses)
40. Gallbladder trouble or gallstones
66. Sleepwalking episodes after age 12
12. Have fluctuating vision or double vision
41. Hepatitis (yellow jaundice)
67. Easily fatigued
13. Have any allergies
42. Hemorrhoids or rectal disease
68. Motion sickness (car, train, sea, or air)
14. Take any medications regularly
43. Black or bloody stools
69. X-ray or other radiation therapy
15. Stutter or stammer
44. Frequent or painful urination
70. Sensitivity to chemicals, dust, sunlight, etc.
16. Frequent, severe, or migraine headaches
45. Bed wetting after age 12
71. Learning disabilities or speech problems
HAVE YOU EVER
17. Fainting or dizzy spells
46. Blood, protein, or sugar in urine
YES
NO
18. Periods of unconsciousness
47. History of diabetes
72. Been refused employment or been unable to
hold a job or stay in school because of:
19. Head injury or skull fracture
48. Kidney stone
20. Epilepsy, seizures or convulsions
49. Hernia or rupture
a. Inability to perform certain movements?
21. Loss of memory (amnesia)
50. Any bone or joint problem, injuries, surgery
b. Inability to assume certain positions?
or medical treatment
22. Depression, anxiety, excessive worry, or
c. Other medical reasons?
nervousness
73. Been rejected for or discharged from military
51. Steel pins, plates, or staples in any bones
service because of physical, mental or other
23. Any mental condition or illness
52. Wear a bone or joint brace or support
reasons?
74. Been denied or rated up for life insurance?
24. Frequent trouble sleeping
53. Back pain or trouble
25. Hearing loss
54. Paralysis or weakness
75. Received or applied for pension or
compensation for existing disability?
26. Ear, nose, or throat trouble
55. Foot trouble/use orthotics
27. Sinusitis or sinus trouble
56. Rheumatic fever
76. Had or been advised to have, any surgical
operations?
28. Hay fever or allergic rhinitis
57. Tuberculosis or positive TB test
77. Consulted, or been treated by clinics,
29. Tooth/gum trouble, or current orthodontics
58. Sexually transmitted disease (syphilis,
hospitals, physicians, healers, or other
gonorrhea, herpes)
30. Thyroid trouble
practitioners for other than minor illnesses?
31. Chronic cough or lung disease
59. Skin conditions such as acne, psoriasis,
78. Had any injury or illness other than those
already noted?
hand or foot rashes, eczema, or dry skin
32. Asthma or wheezing
FEMALES ONLY
YES
NO
33. Unusual shortness of breath
(Complete Items 79 - 82)
60. Adverse reaction to vaccines, drugs,
medicines, foods, insect bites or stings
34. Pain or pressure in chest
79. Been treated for a female disorder, painful
periods, or cramps
35. Palpitation or pounding heart
61. Eating disorder
36. Heart trouble or heart murmur
62. Recent gain or loss of weight
80. Had a change in menstrual pattern
37. High blood pressure
63. Excessive bleeding or easy bruising
81. Are you now pregnant?
82. Date of last menstrual period (YYYYMMDD)
38. Coughed up or vomited blood
64. Tumor, growth, cyst, or cancer
39. Stomach, liver, or intestinal trouble
65. Considered or attempted suicide
DD FORM 2492, MAR 2008
PREVIOUS EDITION IS OBSOLETE.
DoD Exception to SF93 approved by GSA/IRMS (8-91)
Adobe Professional 7.0
Reset
83. REMARKS. Applicant use only. Every "yes" response in items 7 through 81 must be explained in the space provided. Give specific dates and
details including names of physicians and hospitals or clinics and the current status of the condition. If additional space is required, continue on a
separate sheet and attach to this form.
84. CERTIFICATION. I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my
knowledge. I authorize any of the physicians, hospitals, or clinics mentioned above to furnish the Government a complete transcript of my
medical record for purposes of processing my application for this employment or service.
TYPED OR PRINTED NAME OF EXAMINEE/APPLICANT
SIGNATURE OF EXAMINEE/APPLICANT
DATE SIGNED
(YYYYMMDD)
85. EXAMINER'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA. Examiner shall comment on all "Yes" and blank answers,
indicating the item number before each comment. Develop by interview any additional medical history deemed important, and record significant
findings here. If additional space is required, continue on a separate sheet and attach to this form.
87. NUMBER OF
86. EXAMINER
ATTACHED
TYPED OR PRINTED NAME OF EXAMINER
SIGNATURE OF EXAMINER
DATE SIGNED
SHEETS
(YYYYMMDD)
DD FORM 2492 (BACK), MAR 2008
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Download DD Form 2492 DoD Medical Examination Review Board (Dodmerb) Report of Medical History

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How to Fill out DD Form 2492?

Completed forms must be mailed to DoDMERB/DR at 8034 Edgerton Drive, Suite 132, USAF Academy, CO 80840-2200. DD Form 2492 instructions are as follows:

  1. Items 1 through 3 require the name, Social Security Number and phone number of the applicant;
  2. Item 4 requires identifying the purpose of the examination. The name of the examination facility or the name of the examiner along with their full address with ZIP code are entered in Item 5. The date of the examination is specified in Item 6;
  3. The main block of the form is a 75-part questionnaire that requires information about past substance abuse, chronic illnesses, surgeries and any sexually transmitted diseases the applicant may have:
    • Questions 79 through 82 are for female applicants only. Authorized officials may request the applicant's medical records to further clarify their medical history. Any positive answers to questions 7 through 81 have to be explained in Item 83;
    • All explanations should be detailed and include specific dates, physicians' names, the names of hospitals or clinics, and the current health status. If the provided space is not enough, the applicant may attach a copy of the DD Form 2492 as an additional sheet to the form.
  4. Item 84 contains a pre-printed certification and a boxe for the applicant to sign;
  5. Item 85 is completed by the examiner. The box requires their comments on the applicant's answers and actual medical history;
  6. The examiner has to provide their name, date, and signature in the corresponding boxes in Item 86 to certify their statement;
  7. Item 87 requires specifying the total number of sheets attached to the form.
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