DD Form 2351 DoD Medical Examination Review Board (Dodmerb) Report of Medical Examination

DD Form 2351 - also known as the "Dod Medical Examination Review Board (dodmerb) Report Of Medical Examination" - is a Military form issued and used by the United States Department of Defense.

The form - often incorrectly referred to as the DA form 2351 - was last revised on March 1, 2008. Download an up-to-date fillable DD Form 2351 down below in PDF-format or find it on the Department of Defense documentation website.

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DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)
OMB No. 0704-0396
REPORT OF MEDICAL EXAMINATION
OMB approval expires
Nov 30, 2009
(Please read Privacy Act Statement before completing this form.)
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
DODMERB USE ONLY
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 any U.S. Government agency requiring the
information to complete applications to their organizations.
DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection
process and hamper your candidacy. Use of the Social Security Account Number (SSN) is used for
positive identification of records.
APPLICANT DATA
1. DATE OF EXAMINATION (YYYYMMDD)
2. NAME (Last, First, Middle Initial)
3. SOCIAL SECURITY ACCOUNT NUMBER
4. DATE OF BIRTH (YYYYMMDD)
5. AGE
6. SEX
7. RACE (Ethnic Group/Medically Significant)
9. STATUS (X one)
10. EXAMINER ADDRESS AND FACILITY NUMBER.
8. ADDRESS INFORMATION (If left blank will delay processing)
a. APPLICANT MAILING ADDRESS (Include ZIP Code)
ACTIVE DUTY
CIVILIAN
RESERVE/
GUARD
b. ROTC DETACHMENT CODE (If applicable):
MEASUREMENTS
12. WEIGHT (to
14. BLOOD PRESSURE
14.a. REPEAT B/P IF >140/90. REPEAT PULSE IF >99. RECORD RESULTS
13. PULSE
11. HEIGHT (to nearest 1/4 inch)
HERE:
nearest pound)
SYSTOLIC
DIASTOLIC
/
/
SYSTOLIC
DIASTOLIC
PULSE
STANDING
SITTING
16. READING ALOUD TEST
15. AUDIOMETER
500
1000
2000
3000
4000
6000
500
1000
2000
3000
4000
6000
SATISFACTORY
RIGHT
LEFT
UNSATISFACTORY (Explain in Item 57)
17. DISTANT VISION
18. MANIFEST REFRACTION (Required, regardless of corrected/uncorrected
19. NEAR VISION
visual acuity)
RIGHT 20/
CORR TO 20/
SPH
CYL
AXIS
20/
CORR TO 20/
BY
LEFT 20/
CORR TO 20/
SPH
CYL
AXIS
20/
CORR TO 20/
BY
22. COLOR VISION
23. DEPTH PERCEPTION
21. COVER TEST
MTF and MEPS only:
20. HETEROPHORIA/TROPIA
Perform FALANT if applicant
(Far only)
PIP (14 plate test only)
TEST USED
SCORE
PASS
passes 11 or less on PIP.
RH
(Non-Tropia)
VTA-ND/OVT/AFVT
ESO
EXO
LH
No. Passed
Document on DD Form 2489
DPA-V
or SF 600, recording FALANT
FAIL (Tropia)
No. Failed
results per protocol.
TITMUS/STEREO FLY (Arcs/second)
24. NEAR POINT OF CONVERGENCE (in mm)
26. OCULAR MOTILITY AND BINOCULARITY (RED LENS TEST)
25. VIVID RED/GREEN (If item 22
passes 9 or less)
IF FAILED:
PASS
FAIL
PASS
FAIL
DIPLOPIA
SUPPRESSION
LABORATORY
27. URINALYSIS
PROTEIN
NEG
T
1+
2+
3+
4+
MICROSCOPIC EXAMINATION (If required) (X one)
SUGAR
NEG
T
1+
2+
3+
4+
NEGATIVE
BLOOD
NEG
T
1+
2+
3+
4+
POSITIVE (List results)
28. OTHER TESTS (Specify type and results)
DD FORM 2351, MAR 2008
PREVIOUS EDITION IS OBSOLETE.
Reset
DoD Exception to SF 88 Approved by GSA/OIRM 4-88
Adobe Professional 7.0
DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)
OMB No. 0704-0396
REPORT OF MEDICAL EXAMINATION
OMB approval expires
Nov 30, 2009
(Please read Privacy Act Statement before completing this form.)
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
DODMERB USE ONLY
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 any U.S. Government agency requiring the
information to complete applications to their organizations.
DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection
process and hamper your candidacy. Use of the Social Security Account Number (SSN) is used for
positive identification of records.
APPLICANT DATA
1. DATE OF EXAMINATION (YYYYMMDD)
2. NAME (Last, First, Middle Initial)
3. SOCIAL SECURITY ACCOUNT NUMBER
4. DATE OF BIRTH (YYYYMMDD)
5. AGE
6. SEX
7. RACE (Ethnic Group/Medically Significant)
9. STATUS (X one)
10. EXAMINER ADDRESS AND FACILITY NUMBER.
8. ADDRESS INFORMATION (If left blank will delay processing)
a. APPLICANT MAILING ADDRESS (Include ZIP Code)
ACTIVE DUTY
CIVILIAN
RESERVE/
GUARD
b. ROTC DETACHMENT CODE (If applicable):
MEASUREMENTS
12. WEIGHT (to
14. BLOOD PRESSURE
14.a. REPEAT B/P IF >140/90. REPEAT PULSE IF >99. RECORD RESULTS
13. PULSE
11. HEIGHT (to nearest 1/4 inch)
HERE:
nearest pound)
SYSTOLIC
DIASTOLIC
/
/
SYSTOLIC
DIASTOLIC
PULSE
STANDING
SITTING
16. READING ALOUD TEST
15. AUDIOMETER
500
1000
2000
3000
4000
6000
500
1000
2000
3000
4000
6000
SATISFACTORY
RIGHT
LEFT
UNSATISFACTORY (Explain in Item 57)
17. DISTANT VISION
18. MANIFEST REFRACTION (Required, regardless of corrected/uncorrected
19. NEAR VISION
visual acuity)
RIGHT 20/
CORR TO 20/
SPH
CYL
AXIS
20/
CORR TO 20/
BY
LEFT 20/
CORR TO 20/
SPH
CYL
AXIS
20/
CORR TO 20/
BY
22. COLOR VISION
23. DEPTH PERCEPTION
21. COVER TEST
MTF and MEPS only:
20. HETEROPHORIA/TROPIA
Perform FALANT if applicant
(Far only)
PIP (14 plate test only)
TEST USED
SCORE
PASS
passes 11 or less on PIP.
RH
(Non-Tropia)
VTA-ND/OVT/AFVT
ESO
EXO
LH
No. Passed
Document on DD Form 2489
DPA-V
or SF 600, recording FALANT
FAIL (Tropia)
No. Failed
results per protocol.
TITMUS/STEREO FLY (Arcs/second)
24. NEAR POINT OF CONVERGENCE (in mm)
26. OCULAR MOTILITY AND BINOCULARITY (RED LENS TEST)
25. VIVID RED/GREEN (If item 22
passes 9 or less)
IF FAILED:
PASS
FAIL
PASS
FAIL
DIPLOPIA
SUPPRESSION
LABORATORY
27. URINALYSIS
PROTEIN
NEG
T
1+
2+
3+
4+
MICROSCOPIC EXAMINATION (If required) (X one)
SUGAR
NEG
T
1+
2+
3+
4+
NEGATIVE
BLOOD
NEG
T
1+
2+
3+
4+
POSITIVE (List results)
28. OTHER TESTS (Specify type and results)
DD FORM 2351, MAR 2008
PREVIOUS EDITION IS OBSOLETE.
Reset
DoD Exception to SF 88 Approved by GSA/OIRM 4-88
Adobe Professional 7.0
CLINICAL EVALUATION
(X each item in the appropriate column.)
(X each item in the appropriate column.)
ABNOR-
ABNOR-
All evaluations must be addressed, or the
All evaluations must be addressed, or the
NORMAL
NORMAL
MAL
MAL
.
examination is considered INCOMPLETE
examination is considered INCOMPLETE.
29. HEAD, FACE, NECK AND SCALP
44. ENDOCRINE SYSTEM
30. NOSE
45. SPINE, OTHER MUSCULOSKELETAL
31. SINUSES
46. UPPER EXTREMITIES (Strength, sensation, range of motion)
32. MOUTH AND THROAT
(Braces/retainers - permanent/removable)
47. LOWER EXTREMITIES (Except feet) (Strength, sensation,
range of motion)
33. EARS - GENERAL(Internal and external canals)
(Auditory acuity under item 15)
48. FEET (If Pes Planus or Pes Cavus, mild/moderate/severe,
symptomatic/asymptomatic)
34. DRUMS (Perforation and scarring)
35. VALSALVA
49. IDENTIFYING BODY MARKS, SCARS
(length, surgical/
, TATTOOS
, PIERCINGS
nonsurgical)
(description and location)
36. EYES - GENERAL APPEARANCE (Visual acuity and
refraction under items 17, 18, and 19)
50. SKIN, LYMPHATICS (acne, rashes)
37. PUPILS (Equality and reaction)
51. MALE GU SYSTEM - EXTERNAL VISUAL ONLY -
MANDATORY
38. OCULAR MOTILITY (Associated parallel movements,
nystagmus)
52. ANUS AND RECTUM - EXTERNAL VISUAL ONLY -
MANDATORY ON ALL APPLICANTS (Hemorrhoids, fistulae)
39. OPHTHALMOSCOPIC(Required by medical examiner)
40. LUNGS AND CHEST (Include breasts)
53. FEMALE GU SYSTEM - EXTERNAL VISUAL ONLY -
MANDATORY
41. HEART (Thrust, size, rhythm, and sounds)
42. VASCULAR SYSTEM (Varicosities, etc.)
54. NEUROLOGIC
43. ABDOMEN AND VISCERA (Include hernia)
55. PSYCHIATRIC (Specify any personality deviation)
56. EXAMINER: REPEAT BP AND PULSE IF RESULTS OF ITEM 14 AND 14a ARE >140/90 AND >99, RESPECTIVELY.
57. NOTES (Describe every abnormality in detail. Enter the item number before each comment.)
(If performed by PA, PCNP, OR FNP must be countersigned by a MD or DO.)
58. EXAMINER
TYPED OR PRINTED NAME
CORPS OR DEGREE
SIGNATURE
DATE (YYYYMMDD)
59. PHYSICIAN (MD/DO)
TYPED OR PRINTED NAME
DEGREE
SIGNATURE
DATE (YYYYMMDD)
DD FORM 2351 (BACK), MAR 2008
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