DD Form 2766 Adult Preventive and Chronic Care Flowsheet

What Is DD Form 2766?

DD Form 2766, Adult Preventive and Chronic Care Flowsheet is a service-specific patient problem list, consolidating the health condition information to provide streamline care delivery and meet all standards of care. This form is utilized in Armed Forces Health Longitudinal Technology Application (AHTLA) for active duty, U.S. Army Reserve (USAR), and Army National Guard of the United States soldiers as well as non-active duty adult beneficiaries, civilian employees, and contractors receiving care in Military Treatment Facilities (MTFs) as part of their employment.

The latest edition of the document - commonly incorrectly referred to as the DA Form 2766 - was released by the Department of Defense (DoD) in January 2000. An up-to-date DD Form 2766 is available for download below. As of today, no copies of the form can be found on the Executive Services Directorate website.

The DD Form 2766 - along with the SF 601 and CDC Form 731 - belong to a series of forms related to immunization. This form is distributed with the DD Form 2766C, Adult Preventive and Chronic Care Flowsheet (Continuation Sheet), which provides additional space for the information required by the main form.

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ADULT PREVENTION AND CHRONIC CARE FLOWSHEET
(This form is subject to the Privacy Act of 1974 – Use DD form 2005)
1. ALLERGIES
a. MEDICATION ALLERGIES
b. OTHER ALLERGIES
2. CHRONIC ILLNESS
3. MEDICATIONS
4. HOSPITALIZATIONS/SURGERIES
5. COUNSELING
F
FITNESS
a. DATE
D
DENTAL
b. AGE
I
INJURY PREVENTION
c. TOPIC
N
NUTRITION/FOLATE
C
CANCER PREVENTION
S
SAFE SEX
d. DATE
FP
FAMILY PLANNING
e. AGE
RX
PRESENT MEDICATIONS
f. TOPIC
MH
MENTAL HEALTH/STRESS/SUICIDE/
OCCUPATIONAL STRESS
H
HORMONE/CALCIUM REPLACEMENT
g. DATE
To
TOBACCO
h. AGE
A
ALCOHOL/SUBSTANCE ABUSE
i. TOPIC
t
TRAVEL
o
OCCUPATIONAL EXPOSURE
(HEARING THRESHOLD CHANGES/
j. DATE
CUMULATIVE TRAUMA DISORDER)
k. AGE
l. TOPIC
ADVANCE DIRECTIVES: DATE FILED
PATIENT’S IDENTIFICATION
RECORDS MAINTAINED AT:
(Use this space for mechanical imprint)
PATIENT’S NAME
SEX
LAST
FIRST
M.I.
SUPPLIED (Navy)
RELATIONSHIP TO SPONSOR STATUS
RANK/GRADE
2766-0102-LF-984-8400, pkg-100
SPONSOR’S NAME (Last, First, Middle Initial)
DEPT/SERVICE
ORGANIZATION
SSN/ID NUMBER
DATE OF BIRTH
DD FORM 2766, (Rev. 01-00)
PAGE 1 of 4 PAGES
Reset
ADULT PREVENTION AND CHRONIC CARE FLOWSHEET
(This form is subject to the Privacy Act of 1974 – Use DD form 2005)
1. ALLERGIES
a. MEDICATION ALLERGIES
b. OTHER ALLERGIES
2. CHRONIC ILLNESS
3. MEDICATIONS
4. HOSPITALIZATIONS/SURGERIES
5. COUNSELING
F
FITNESS
a. DATE
D
DENTAL
b. AGE
I
INJURY PREVENTION
c. TOPIC
N
NUTRITION/FOLATE
C
CANCER PREVENTION
S
SAFE SEX
d. DATE
FP
FAMILY PLANNING
e. AGE
RX
PRESENT MEDICATIONS
f. TOPIC
MH
MENTAL HEALTH/STRESS/SUICIDE/
OCCUPATIONAL STRESS
H
HORMONE/CALCIUM REPLACEMENT
g. DATE
To
TOBACCO
h. AGE
A
ALCOHOL/SUBSTANCE ABUSE
i. TOPIC
t
TRAVEL
o
OCCUPATIONAL EXPOSURE
(HEARING THRESHOLD CHANGES/
j. DATE
CUMULATIVE TRAUMA DISORDER)
k. AGE
l. TOPIC
ADVANCE DIRECTIVES: DATE FILED
PATIENT’S IDENTIFICATION
RECORDS MAINTAINED AT:
(Use this space for mechanical imprint)
PATIENT’S NAME
SEX
LAST
FIRST
M.I.
SUPPLIED (Navy)
RELATIONSHIP TO SPONSOR STATUS
RANK/GRADE
2766-0102-LF-984-8400, pkg-100
SPONSOR’S NAME (Last, First, Middle Initial)
DEPT/SERVICE
ORGANIZATION
SSN/ID NUMBER
DATE OF BIRTH
DD FORM 2766, (Rev. 01-00)
PAGE 1 of 4 PAGES
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ADULT PREVENTION AND CHRONIC CARE FLOWSHEET
6. FAMILY HISTORY
M = Mother, F = Father, S = Sibling, MGM = Maternal Grandmother, MGF – Maternal Grandfather,
PGM = Paternal Grandmother, PGF = Paternal Grandfather)
a. CANCER
(Specify)
b. CARDIOVASCULAR DISEASE (Specify)
c. DIABETES (Specify)
d. MENTAL ILLNESS/CHEMICAL DEPENDENCY (Specify)
7. SCREENING EXAMS (* = Actual Result, ** = Tricare Benefit, N = Normal, X = Abnormal, E = Done Elsewhere, R =
Refused, NA = Not Indicated) (
= Next Due)
c. YEAR
a. TEST
b. FREQUENCY
d. AGE
(1) CLINICAL DISEASE
ANNUAL
e. DATES
PREV EVAL/PHA (HEAR)
*
ANNUAL FOR ACTIVE DUTY
(2) WEIGHT
*
ANNUAL FOR ACTIVE DUTY
(3) HEIGHT
ONCE q 2 YRS FOR BP <
*
(4) BLOOD PRESSURE
130/85, ANNUAL IF GREATER
*q 5 YRS FOR AGE > 18
*
**
(5) CHOLESTEROL
q YR IF PREV ABN
(6) HEARING
CLINICAL DISCRETION
(7) SKIN EXAM (Cancer)
ANNUAL IF AT RISK
(8) ORAL/DENTAL **
ANNUAL
ROUTINE ACUITY WITH PERIODIC
ASSESSMENT DIABETES ANNUAL
(9) EYE/VISION**
GLAUCOMA CHECK:
Blacks q 3-5 yrs age 20-29
All q 2-4 years age 40-64
(10) BREAST EXAM
ANNUAL: > 40 YRS
(11) MAMMOGRAM**
BASELINE @ 40, q 2 YRS
40-50, ANNUALLY > 50
BASELINE: AGE 18 OR ONSET OF
SEXUAL ACTIVITY
(12) PAP
AFTER 3 NL ANNUAL EXAMS,
**(Digital Rectal Exam)
PERFORM q 1-3 years.
(13) FECAL OCCULT
ANNUAL > 50 yrs
BLOOD
(14) SIGMOID
EVERY 3-5 YRS: > 50 YRS
(15) COLONOSCOPY
HIGH RISK q 5 YRS > 40 YRS
(16) TESTICULAR
HIGH RISK ANNUAL 13-39 YRS
WITH P.E. > 40 YRS (Presently
(17) PROSTATE**
recommended annually)
**(DIGITAL RECTAL EXAM)
(18) RUBELLA SCREEN
ONCE BETWEEN AGES 12-18 YRS
(Females)
(Unless prev vaccinated)
(19) OCCUPATIONAL
APPROPRIATE TO EXPOSURES
SCREENING EXAMS
(20)
(21)
(22)
DD FORM 2766, (Rev. 01-00)
PAGE 2 of 4 PAGES
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ADULT PREVENTION AND CHRONIC CARE FLOWSHEET
8. OCCUPATIONAL HISTORY/RISK
a.
PRP
YES
NO
b.
FLYING STATUS
YES
NO
9. IMMUNIZATIONS (Enter numeric class in sub block)
(1)
2) DATE
(1)
2) DATE
(1)
2) DATE
(1)
2) DATE
(
(
(
(
(ddmmmyyyy)
(ddmmmyyyy)
(ddmmmyyyy)
(ddmmmyyyy)
IMMUNIZATION
IMMUNIZATION
IMMUNIZATION
IMMUNIZATION
a. HEP A #1
f. MMR #1
j. TD (q 10 YRS)
(Last)
k. TD (DUE)
b. HEP A #2
g. MMR #2
c. HEP B #1
h.
l. YELLOW
FEVER (LAST)
PNEUMOCOCCUS
d. HEP B #2
i. POLIO OPV=O
m. YELLOW
IPV = I
FEVER
n. TYPHOID (Enter numeric class
(1) DATE
(2) DATE
(3) DATE
(4) DATE
(5) DATE
(6) DATE
in sub block)
Oral=O, TYPHUM
VI=1, TYPHOID USP = 2
(1) INITIAL DATE (2) 2 WEEK DATE
(3) 4 WEEK DATE
(4) 6 MONTH DATE
(5) 12 MONTH DATE
(6) 18 MONTH DATE
o. ANTHRAX
p. PPD (Enter
(1)(a) mm
(2)(a) mm
(3)(a) mm
(4)(a) mm
(5)(a) mm
(6)(a) mm
(7)(a) mm
mm and date)
(b) DATE
(b) DATE
(b) DATE
(b) DATE
(b) DATE
(b) DATE
(b) DATE
q. INFLUENZA (1) DATE
(2) DATE
(3) DATE
(4) DATE
(5) DATE
(6) DATE
(7) DATE
r. VARICELLA (1) DATE
(2) DATE
u. JAPANESE
(1) DATE
(2) DATE
(3) DATE
(4) DATE
ENCEPHALITIS
v. OTHER (Specify)
s. MENINGO
(1) DATE
(2) DATE
(1) DATE
(2) DATE
(3) DATE
w. OTHER (Specify)
t. ADENO
(1) DATE
(2) DATE
(1) DATE
(2) DATE
(3) DATE
10. READINESS
(Glucose-6-phosphate dehydrogenase)
a. DNA DATE:
b. BLOOD
DATE:
RESULT:
c. G-PD
DATE:
RESULT:
d. SICKLE
DATE:
RESULT:
TYPE
CELL
(1) DATE
(2) P:
(3) U:
(4) L:
(5) H:
(6) E:
(7) S:
e. PERMANENT PROFILE CHANGE
f. GLASSES/GAS/MASK
(1) DATE
(2) DATE
(3) DATE
(4) DATE
(5) DATE
(6) DATE
Rx:
g. DENTAL EXAM (Enter
(1) DATE
(2) DATE
(3) DATE
(4) DATE
(5) DATE
(6) DATE
numeric class in sub block)
(1) DATE
(2) DATE
(3) DATE
(4) DATE
(5) DATE
(6) DATE
h. HIV TESTING
i. FITNESS (in sub block enter
(1) DATE
(2) DATE
(3) DATE
(4) DATE
(5) DATE
(6) DATE
P=Pass, F=Fail, W=Waiver)
(1) DATE
(2) DATE
(3) DATE
(4) DATE
(5) DATE
(6) DATE
(1) DATE
(2) DATE
(3) DATE
(4) DATE
(5) DATE
(6) DATE
11. PRE/POST DEPLOYMENT HISTORY
a. LOCATION
(1) PREDEPLOYMENT
(a) DATE
(b) DATE
(c) DATE
(d) DATE
(e) DATE
(f) DATE
(2) POSTDEPLOYMENT
(a) DATE
(b) DATE
(c) DATE
(d) DATE
(e) DATE
(f) DATE
b. LOCATION
(1) PREDEPLOYMENT
(a) DATE
(b) DATE
(c) DATE
(d) DATE
(e) DATE
(f) DATE
(2) POSTDEPLOYMENT
(a) DATE
(b) DATE
(c) DATE
(d) DATE
(e) DATE
(f) DATE
c. CHART AUDIT
DD FORM 2766, (Rev. 01-00)
PAGE 3 of 4 PAGES
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ADULT PREVENTION AND CHRONIC CARE FLOWSHEET
(Continuation Sheet)
DATES
a. TEST
b. FREQUENCY
(a)
(b)
(c)
(d)
(e)
(f)
REMARKS
RECORDS MAINTAINED AT:
PATIENT’S NAME
SEX
LAST
FIRST
M.I.
RELATIONSHIP TO SPONSOR STATUS
RANK/GRADE
SPONSOR’S NAME (Last, First, Middle Initial)
DEPT/SERVICE
ORGANIZATION
SSN/ID NUMBER
DATE OF BIRTH
DD FORM 2766, (Rev. 01-00)
PAGE 4 of 4 PAGES
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Download DD Form 2766 Adult Preventive and Chronic Care Flowsheet

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How to Fill out DD Form 2766?

Additional guidelines can be found in the Army Regulation 40-66 (Medical Record Administration and Healthcare Documentation). DD Form 2766 instructions are as follows:

  1. The form can be used in two ways: either as a folder or as a cut-sheet. The folder-version of the DD 2766 is used for active duty personnel. During deployments, the form serves as a treatment folder. The cut sheet is used for non-active duty personnel. This version consists only of the first two pages of the form. When using the DD 2766 as a cut sheet, all of the immunization documentation should be done on the SF 601.
  2. The identification block can contain either the stamp from the patients recording card or an ID label. The other required data should be entered manually.
  3. Block 1 requires any taken medication and any allergies within the recorded time frame.
  4. Block 2 should contain a list of all chronic illnesses the patient may have. Block 3 - Medications - should be completed in ink and must contain a list of names and starting dates of prescribed medications except for those taken for acute and short-term illnesses.
  5. Block 4 should contain the data about any prior hospitalizations and surgeries with their dates.
  6. Block 5 is for recording the counseling. The lines titled "Date," "Age," and "Topic" should be filled in only during the annual prevention assessment.
  7. Block 6 is for family history. Any of the listed diseases the patient's relatives may have had need to be recorded in the corresponding lines.
  8. Block 7 - Screening Exams - contains the list of medical exams ranging from general to specific. This block requires the age of the patient at the moment of the examination along with the date of the test performance and its results.
  9. Block 8 should contain information on any exposure hazards. Block 9 is for the information on the immunization the patient has already had.
  10. Block 10 is for the readiness information.
  11. Block 11 - Pre/Post Deployment History - should contain the date of each deployment and the location and date of each evaluation. However, the record of deployment for classified operations will be maintained only in the personnel folder.
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