DA Form 3437 Certificate of Medical Examination

What Is DA Form 3437?

DA Form 3437, Department of the Army Nonappropriated Funds - Certificate of Medical Examination is an official form used to record the results of a pre-employment physical examination of NAF employees. The certificate can also be used during periodic job-related physical tests. An up-to-date DA Form 3437 fillable version is available for filing and download below or can be found through the Army Publishing Directorate website.

The DA 3437 is necessary for the position that may require the employee to:

  • Operate motor vehicles;
  • Have direct physical contact with people (especially when applying for childcare-related positions);
  • Work underground, in dangerous conditions, or around power-driven machinery;
  • Undergo exertion, dangerous duty, or excessive physical demands;
  • Be in contact with food that will be consumed by others.

The most recent version of the form - sometimes incorrectly referred to as the DD Form 3437 - was released by the Department of the Army (DA) in August 2016 with the previous editions obsolete.

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DEPARTMENT OF THE ARMY
For use of this form, see AR 215-3; the
(Applicant must supply information
below to heavy line)
NONAPPROPRIATED FUNDS
proponent agency is DCS, G1.
CERTIFICATE OF MEDICAL EXAMINATION
(Typewrite or Print in Ink)
1. NAME (CAPS) LAST - FIRST - MIDDLE
MR. - MISS - MRS.
2. SEX
3. BIRTH DATE
(Mo., day, year)
MALE
FEMALE
4. STREET ADDRESS AND APARTMENT NO.
5. CITY, STATE, AND ZIP CODE
6. POSITION TITLE AND NUMBER
7. PAY PLAN AND
8. GRADE OR LEVEL
9. SALARY
OCCUPATION CODE
10. NAME AND LOCATION OF EMPLOYING OFFICE
11. (A) ARE YOU NOW EMPLOYED IN POSITION SHOWN IN ITEM 7
(B) IF "YES" GIVE THE DATE OF YOUR ORIGINAL APPOINTMENT
TO THIS POSITION:
YES
NO
13. (A) HAVE YOU ANY PHYSICAL DEFECT OR DISABILITY WHATSOEVER?
YES
NO
IF "YES", GIVE DETAILS.
(B) DOES THE VETERANS ADMINISTRATION RECOGNIZE SERVICE-CONNECTED DISABILITY IN YOUR CASE?
YES
NO
(C) HAVE YOU EVER RECEIVED DISABILITY RETIREMENT FROM THE U.S. CIVIL SERVICE COMMISSION OR
YES
NO
A NONAPPROPRIATED FUND ACTIVITY?
Sign your name in INK as it appears on your application in the presence of the
physician for purpose of identification.
DOCTOR: All questions on both sides of this certificate and on the lower half of the attached Health Qualification Placement Record must be answered. Before
beginning the examination, refer to items 13 and 14 on the Health Qualification Placement Record so that you will have a knowledge of the physical requirements
of the position to which the applicant is to be appointed. Sign both this certificate and the Health Qualification Placement Record
1. HEIGHT:
FEET
INCHES
WEIGHT:
POUNDS
20
20
20
20
2. EYES:
(A) DISTANT VISION (Snellen):
WITHOUT GLASSES: RIGHT
LEFT
WITH GLASSES, IF WORN: RIGHT
LEFT
(B) WHAT IS THE LONGEST AND SHORTEST DISTANCE AT WHICH THE FOLLOWING SPECIMEN OF JAEGER NO. 2 TYPE CAN BE READ BY THE AP-
PLICANT? TEST EACH EYE SEPARATELY.
WITHOUT GLASSES:
WITH GLASSES, IF WORN:
R.
IN. TO
IN.
R.
IN. TO
IN.
L.
IN. TO
IN.
L.
IN. TO
IN.
(C) EVIDENCE OF DISEASE OR INJURY:
RIGHT
LEFT
(D) COLOR VISION: IS COLOR VISION NORMAL WHEN ISHIHARA OR OTHER COLOR PLATE TEST IS USED?
YES
NO
IF NOT, CAN APPLICANT PASS LANTERN, YARN, OR OTHER COMPARABLE TEST?
YES
NO
3. EARS: (CONSIDER DENOMINATORS INDICATED HERE AS NORMAL. RECORD AS NUMERATORS THE GREATEST DISTANCE HEARD)
ORDINARY CONVERSATION:
RIGHT EAR
LEFT EAR
EVIDENCE OF DISEASE OR INJURY: RIGHT EAR
LEFT EAR
20 FT.
20 FT.
4. NOSE
5. PARA NASAL SINUSES
6. MOUTH AND THROAT
7. GASTRO-INTESTINAL
(A) HISTORY OF PEPTIC ULCER:
YES
NO
IF "YES", IS ULCER:
ACTIVE
QUIESCENT
HEALED
HOW LONG?
DATE OF LAST X-RAY
SYMPTOMS PRESENT, IF ANY (Severity, frequency, etc.):
TREATMENT (Use space under "Remarks," if needed):
8. METABOLIC DISORDERS: (INDICATE ANY ABNORMALITY OF THE FOLLOWING GLANDS BY A CHECK IN THE APPROPRIATE BOX, AND EXPLAIN UNDER
"REMARKS.")
THYROID
PANCREAS
PITUITARY
OVARIAN
DA FORM 3437, AUG 2016
PREVIOUS EDITONS ARE OBSOLETE.
PAGE 1 OF 6
APD LC v1.00ES
DEPARTMENT OF THE ARMY
For use of this form, see AR 215-3; the
(Applicant must supply information
below to heavy line)
NONAPPROPRIATED FUNDS
proponent agency is DCS, G1.
CERTIFICATE OF MEDICAL EXAMINATION
(Typewrite or Print in Ink)
1. NAME (CAPS) LAST - FIRST - MIDDLE
MR. - MISS - MRS.
2. SEX
3. BIRTH DATE
(Mo., day, year)
MALE
FEMALE
4. STREET ADDRESS AND APARTMENT NO.
5. CITY, STATE, AND ZIP CODE
6. POSITION TITLE AND NUMBER
7. PAY PLAN AND
8. GRADE OR LEVEL
9. SALARY
OCCUPATION CODE
10. NAME AND LOCATION OF EMPLOYING OFFICE
11. (A) ARE YOU NOW EMPLOYED IN POSITION SHOWN IN ITEM 7
(B) IF "YES" GIVE THE DATE OF YOUR ORIGINAL APPOINTMENT
TO THIS POSITION:
YES
NO
13. (A) HAVE YOU ANY PHYSICAL DEFECT OR DISABILITY WHATSOEVER?
YES
NO
IF "YES", GIVE DETAILS.
(B) DOES THE VETERANS ADMINISTRATION RECOGNIZE SERVICE-CONNECTED DISABILITY IN YOUR CASE?
YES
NO
(C) HAVE YOU EVER RECEIVED DISABILITY RETIREMENT FROM THE U.S. CIVIL SERVICE COMMISSION OR
YES
NO
A NONAPPROPRIATED FUND ACTIVITY?
Sign your name in INK as it appears on your application in the presence of the
physician for purpose of identification.
DOCTOR: All questions on both sides of this certificate and on the lower half of the attached Health Qualification Placement Record must be answered. Before
beginning the examination, refer to items 13 and 14 on the Health Qualification Placement Record so that you will have a knowledge of the physical requirements
of the position to which the applicant is to be appointed. Sign both this certificate and the Health Qualification Placement Record
1. HEIGHT:
FEET
INCHES
WEIGHT:
POUNDS
20
20
20
20
2. EYES:
(A) DISTANT VISION (Snellen):
WITHOUT GLASSES: RIGHT
LEFT
WITH GLASSES, IF WORN: RIGHT
LEFT
(B) WHAT IS THE LONGEST AND SHORTEST DISTANCE AT WHICH THE FOLLOWING SPECIMEN OF JAEGER NO. 2 TYPE CAN BE READ BY THE AP-
PLICANT? TEST EACH EYE SEPARATELY.
WITHOUT GLASSES:
WITH GLASSES, IF WORN:
R.
IN. TO
IN.
R.
IN. TO
IN.
L.
IN. TO
IN.
L.
IN. TO
IN.
(C) EVIDENCE OF DISEASE OR INJURY:
RIGHT
LEFT
(D) COLOR VISION: IS COLOR VISION NORMAL WHEN ISHIHARA OR OTHER COLOR PLATE TEST IS USED?
YES
NO
IF NOT, CAN APPLICANT PASS LANTERN, YARN, OR OTHER COMPARABLE TEST?
YES
NO
3. EARS: (CONSIDER DENOMINATORS INDICATED HERE AS NORMAL. RECORD AS NUMERATORS THE GREATEST DISTANCE HEARD)
ORDINARY CONVERSATION:
RIGHT EAR
LEFT EAR
EVIDENCE OF DISEASE OR INJURY: RIGHT EAR
LEFT EAR
20 FT.
20 FT.
4. NOSE
5. PARA NASAL SINUSES
6. MOUTH AND THROAT
7. GASTRO-INTESTINAL
(A) HISTORY OF PEPTIC ULCER:
YES
NO
IF "YES", IS ULCER:
ACTIVE
QUIESCENT
HEALED
HOW LONG?
DATE OF LAST X-RAY
SYMPTOMS PRESENT, IF ANY (Severity, frequency, etc.):
TREATMENT (Use space under "Remarks," if needed):
8. METABOLIC DISORDERS: (INDICATE ANY ABNORMALITY OF THE FOLLOWING GLANDS BY A CHECK IN THE APPROPRIATE BOX, AND EXPLAIN UNDER
"REMARKS.")
THYROID
PANCREAS
PITUITARY
OVARIAN
DA FORM 3437, AUG 2016
PREVIOUS EDITONS ARE OBSOLETE.
PAGE 1 OF 6
APD LC v1.00ES
9. HEART AND BLOOD VESSELS
(A) BLOOD PRESSURE:
SYSTOLIC
MM. HG.
DIASTOLIC
(C) IF ORGANIC HEART DISEASE IS PRESENT, IS IT FULLY COMPENSATED?
(B) IS ORGANIC HEART DISEASE PRESENT?
YES
NO
YES
NO
(D) PULSE RATE:
SITTING
IMMEDIATELY AFTER EXERCISE (UNLESS CONTRAINDICATED)
TWO MINUTES AFTER EXERCISE
CARDIAC RESERVE
(GOOD, FAIR, OR POOR)
10. LUNGS:
RIGHT
LEFT
HISTORY OF TUBERCULOSIS?
YES
NO. IF "YES", HOW LONG HAS THE DISEASE BEEN ARRESTED?
YES
NO. IF "YES," GIVE
IF THERE IS HISTORY OF TUBERCULOSIS, IS ANY TYPE OF COLLAPSE THERAPY BEING RECEIVED AT PRESENT?
FULL DETAILS UNDER "REMARKS." IS MEDICAL SUPERVISION NECESSARY?
YES
NO
(IF X-RAY IS MADE, GIVE REPORT UNDER "REMARKS.")
11. HERNIA:
YES
NO. IF "YES", NAME VARIETY: INGUINAL, VENTRAL, FEMORAL, POST-OPERATIVE, ETC.:
IF PRESENT, IS IT SUPPORTED BY A WELL-FITTING TRUSS?
YES
NO
12. VARICOSE VEINS:
YES
NO. IF "YES", STATE LOCATION AND DEGREE.
13. FEET: IS FLAT FOOT PRESENT?
YES
NO. IF "YES", STATE DEGREE OF IMPAIRMENT OF FUNCTION
(NONE, SLIGHT, MODERATE, SEVERE)
14. DEFORMITIES, ATROPHIES, AND OTHER ABNORMALITIES, DISEASE NOT INCLUDED ABOVE
15. SCARS OF SERIOUS INJURY OR DISEASE
16. NERVOUS SYSTEM: (A) INCLUDE SYMPTOMS AND FULL HISTORY OF ANY MENTAL, NERVOUS OR EMOTIONAL ABNORMALITY (USE ADDITIONAL
SHEETS IF NECESSARY.):
YES
NO
(B) HAS APPLICANT EVER BEEN HOSPITALIZED OR TREATED FOR A MENTAL ILLNESS?
(C) WHERE (NAME AND LOCATION OF HOSPITAL):
(D) DATE OR DATES OF HOSPITALIZATION:
(E) DESCRIBE ANY RESIDUALS OF PREVIOUS MENTAL OR NERVOUS ILLNESS:
(F) ANY HISTORY OF EPILEPSY OR FAINTING SPELLS?
YES
NO. IF SO, GIVE DETAILS UNDER "REMARKS" BELOW.
17. EVIDENCE OR HISTORY OF VENEREAL DISEASE: IF BLOOD SEROLOGY OR OTHER LABORATORY EXAMINATIONS ARE MADE, GIVE DETAILS UNDER
"REMARKS."
18. URINALYSIS (IF INDICATED):
SP. GR
ALBUMEN
SUGAR
CASTS
BLOOD
PUS
I HAVE FOUND THE APPLICANT ABNORMAL UNDER THE FOLLOWING HEADINGS:
REMARKS:
19. SIGNATURE OF PHYSICIAN OR EXAMINER
NAME TYPED OR PRINTED
DATE
20. ADDRESS OF EXAMINING PHYSICIAN (Typed or printed)
DA FORM 3437, AUG 2016
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HEALTH QUALIFICATION PLACEMENT RECORD
(NONAPPROPRIATED FUNDS)
1. NAME
LAST - FIRST - MIDDLE
MR. - MISS - MRS.
2. SEX
3. BIRTH DATE
(CAPS)
(Mo., day, year)
MALE
FEMALE
5. STREET ADDRESS AND APARTMENT NO.
6. CITY, STATE, AND ZIP CODE
7. POSITION TITLE AND NUMBER
8. PAY PLAN AND
9. GRADE OR LEVEL
10. SALARY
OCCUPATION CODE
11. NAME AND LOCATION OF EMPLOYING OFFICE
12. (A) ARE YOU NOW EMPLOYED IN POSITION SHOWN IN ITEM 7
(B) IF "YES" GIVE THE DATE OF YOUR ORIGINAL APPOINTMENT
TO THIS POSITION:
YES
NO
TO BE COMPLETED BY APPOINTING OFFICER: SECTIONS 13 AND 14
(A). BRIEF OUTLINE OF WHAT WORKER DOES
(B). PHYSICAL DEMANDS OF THE POSITION
For the physician's use, set down in brief and simple terms what the
In Section 14 below, encircle the number of those factors which are
employee does on this job, including environmental details such as stairs to
essential to the duties of the position for which this applicant is being
climb, distance to rest room facilities, cafeteria, workshift, etc. (Use
considered. The blank spaces may be used for special factors not
Section 13 below.)
listed.
13. TITLE OF POSITION AND OUTLINE OF WHAT WORKER DOES IN THIS POSITION (Advise use of dictionary of occupational titles as guide, as applicable)
TO BE COMPLETED BY EXAMINING PHYSICIAN: SECTIONS 14 THROUGH 20
INSTRUCTIONS: The items circled below indicate the physical
requirements not encircled or not covered by this form, indicate these
requirements of the position for which this individual is being considered.
under "Remarks" on the reverse side. Whenever PARTIAL
capacity has been indicated, explain under "Remarks," giving
Indicate the individual's physical capacities for this position by placing an
X in the appropriate column opposite the numbers encircled. If the
specific quantities.
individual has any other physical limitations relating to physical
14. PHYSICAL REQUIREMENTS
ENVIRONMENTAL FACTORS
CAPACITY
CAPACITY
FULL
PARTIAL
NONE
FULL
PARTIAL
NONE
1. OUTSIDE
18. WORKING AROUND MACHINERY WITH MOVING PARTS
2. OUTSIDE AND INSIDE
19. MOVING OBJECTS OR VEHICLES
3. EXCESSIVE HEAT
20. WORKING ON LADDERS OR SCAFFOLDING
4. EXCESSIVE COLD
21. WORKING BELOW GROUND
5. EXCESSIVE HUMIDITY
22. UNUSUAL FATIGUE FACTORS (Specify)
6. EXCESSIVE DAMPNESS OR CHILLING
7. DRY ATMOSPHERIC CONDITIONS
23. WORKING WITH HANDS IN WATER
8. EXCESSIVE NOISE, INTERMITTENT
24. EXPLOSIVES
9. CONSTANT NOISE
25. VIBRATION
10. DUST
26. WORKING CLOSELY WITH OTHERS
11. SILICA, ASBESTOS, ETC.
27. WORKS ALONE
12. FUMES, SMOKE, OR GASES
28. PROTRACTED OR IRREGULAR HOURS OF WORK
29. SPECIAL FACTORS (Specify)
13. SOLVENTS (Degreasing agents)
14. GREASES AND OILS
15. RADIANT ENERGY
16. ELECTRICAL ENERGY
17. SLIPPERY OR UNEVEN WALKING SURFACES
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DA FORM 3437, AUG 2016
APD LC v1.00ES
14. PHYSICAL REQUIREMENTS (Continued)
FUNCTIONAL FACTORS
CAPACITY
CAPACITY
FULL
PARTIAL
NONE
FULL
PARTIAL
NONE
33. HEAVY LIFTING - 45 POUNDS AND OVER
54. ABILITY FOR RAPID MENTAL AND MUSCULAR
COORDINATION SIMULTANEOUSLY
34. MODERATE LIFTING - 15-44 POUNDS
35. LIGHT LIFTING - UNDER 15 POUNDS
55. ABILITY TO USE AND DESIRABILITY OF USING
FIREARMS
36. HEAVY CARRYING - 45 POUNDS AND OVER
37. MODERATE CARRYING - 15-44 POUNDS
56. NEAR VISION CORRECTIBLE AT 13 TO 16 INCHES TO
(Jaeger 1 to 4)
38. LIGHT CARRYING - UNDER 15 POUNDS
39. STRAIGHT PULLING (
HOURS)
57. FAR VISION CORRECTIBLE TO 20/20 TO 20/40
40. PULLING - HAND OVER HAND (
HOURS)
58. FAR VISION CORRECTIBLE TO 20/50 TO 20/100
59. SPECIFIC VISUAL REQUIREMENT (Specify)
41. PUSHING (
HOURS)
42. REACHING ABOVE SHOULDER
43. USE OF FINGERS
60. BOTH EYES REQUIRED
61. DEPTH PERCEPTION
44. BOTH HANDS REQUIRED
45. WALKING (
HOURS)
62. ABILITY TO DISTINGUISH BASIC COLORS
46. STANDING (
HOURS)
63. ABILITY TO DISTINGUISH SHADES OF COLORS
47. CRAWLING (
HOURS)
64. HEARING (Aid permitted)
48. KNEELING (
HOURS)
65. HEARING WITHOUT AID
66. SPECIFIC HEARING REQUIREMENTS (Specify)
49. REPEATED BENDING (
HOURS)
50. CLIMBING - LEGS ONLY (
HOURS)
51. CLIMBING - USE OF LEGS AND ARMS
67.
52. BOTH LEGS REQUIRED
68.
69.
53. OPERATION OF CRANE, TRUCK, TUG, TRACTOR,
OR MOTOR VEHICLE
70.
15. THIS PERSON SHOULD USE: (A) PROPERLY FITTED EYEGLASSES
(B) PROPERLY FITTED HEARING AID
(C) OTHER PROSTHETIC AID (Specify)
16. REMARKS AND RECOMMENDATIONS:
17. PHYSICAL HANDICAP CODE
18. SIGNATURE OF PHYSICIAN OR EXAMINER
NAME TYPED OR PRINTED
DATE
19. ADDRESS OF EXAMINING PHYSICIAN (Typed or printed)
TO BE COMPLETED BY SUPERVISOR
20. POSITION TO WHICH INDIVIDUAL WAS ASSIGNED
21. SIGNATURE OF SUPERVISOR
NAME TYPED OR PRINTED
DATE
DA FORM 3437, AUG 2016
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PHYSICAL HANDICAP CODE INSTRUCTIONS
If the person examined has or has had a handicap which is listed on the back of
these instructions, enter the code number in Item No. 17 on the Health
Qualification Placement Record.
If more than one handicap applies, enter the one you think most limiting. If
none of the handicaps apply, enter the code "00."
Detach these instructions after entering Physical Handicap Code on the Health
Qualification Placement Record.
DA FORM 3437, AUG 2016
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APD LC v1.00ES

Download DA Form 3437 Certificate of Medical Examination

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How to Fill Out DA Form 3437?

The medical certificate, in general, is a written statement from a medical worker which describes results of a medical examination. It can be used as a sick note or as evidence of a certain health condition.

Procedural guidelines and additional information can be found in the AR 215-3, Nonappropriated Funds Instrumentalities Personnel Policy, released in September 2015. Specific DA Form 3437 instructions are as follows:

  1. Personnel working in child care-related positions must undergo annual medical assessments that include a TB skin test, a chest X-ray, be vaccinated for measles, mumps, rubella, diphtheria, tetanus, and polio with all results recorded on their DA 3437
  2. Along with the original certificate, the civil employee's personnel folder must contain the following forms:
  3. A DA Form 3437 is authorized for filing in the Civilian employee medical records folder. The Civilian employee medical records folder - or CEMR, for short - may be maintained either in the terminal digit filing system DA Form 3444-series or the Standard Form 66D during the entire course of working with the Department of the Army.
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