DD Form 2697 Report of Medical Assessment

What Is DD Form 2697?

DD Form 2697, Report of Medical Assessment is a form used by the Medical Services to provide a comprehensive medical assessment for active and reserve component servicemembers separating or retiring from active duty. A copy of the Soldier's assessment will be later be released to the Department of Veterans Affairs.

The latest version of the DD Form 2967- sometimes incorrectly referred to as the DA Form 2697 - was released by the Department of Defense in February 1995. An up-to-date DD Form 2697 fillable version is available for download and online filing below or can be found through the Executive Services Directorate website.

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REPORT CONTROL SYMBOL
REPORT OF MEDICAL ASSESSMENT
DD-HA(AR)1939
PRIVACY ACT STATEMENT
AUTHORITY: PL 103-160, EO 9397.
PRINCIPAL PURPOSE: To be used by the Medical Services to provide a comprehensive medical assessment for active and reserve component
service members separating or retiring from active duty.
ROUTINE USES: A copy of this form will be released to the Department of Veterans Affairs.
DISCLOSURE: Voluntary; however, failure to disclose the requested personal information may result in delay in processing any disability claim.
SECTION I - TO BE COMPLETED BY SERVICE MEMBER. Any service member who requests a physical examination may have one.
1.
NAME
(Last, First, Middle)
2.
SOCIAL
SECURITY NUMBER
3. RANK
4.
COMPONENT
5.
UNIT
OF ASSIGNMENT
6a. HOME STREET ADDRESS (Or RFD, including
b. CITY
c. STATE
d. ZIP CODE
7.
HOME
TELEPHONE NUMBER
apartment number)
(Include area code)
8.
DATE OF LAST
PHYSICAL EXAMINATION BY THE MILITARY
9.
DATE ENTERED ON
CURRENT ACTIVE DUTY (YYMMDD)
(YYMMDD)
10. COMPARED TO MY LAST MEDICAL ASSESSMENT/PHYSICAL EXAMINATION, MY OVERALL HEALTH IS (X one. If "Worse," explain.)
THE SAME
BETTER
WORSE
11.
SINCE YOUR
LAST MEDICAL ASSESSMENT/PHYSICAL EXAMINATION, HAVE YOU HAD ANY ILLNESSES OR INJURIES THAT CAUSED
YOU TO MISS DUTY FOR LONGER THAN 3 DAYS? (X one. If "Yes," explain.)
NO
YES
12.
SINCE YOUR LAST
MEDICAL ASSESSMENT/PHYSICAL EXAMINATION, HAVE YOU BEEN SEEN BY OR BEEN TREATED BY A HEALTH
CARE PROVIDER, ADMITTED TO A HOSPITAL, OR HAD SURGERY? (X one. If "Yes," explain.)
NO
YES
13. HAVE YOU SUFFERED FROM ANY INJURY OR ILLNESS WHILE ON ACTIVE DUTY FOR WHICH YOU DID NOT SEEK MEDICAL CARE?
(X one. If "Yes," explain.)
NO
YES
14.
ARE YOU
NOW TAKING ANY MEDICATIONS? (X one. If "Yes," list medications.)
NO
YES
15. DO YOU HAVE ANY CONDITIONS WHICH CURRENTLY LIMIT YOUR ABILITY TO WORK IN YOUR PRIMARY MILITARY SPECIALTY OR
REQUIRE GEOGRAPHIC OR ASSIGNMENT LIMITATIONS? (X one. If "Yes," explain.)
NO
YES
16.
DO
YOU HAVE ANY DENTAL PROBLEMS? (X one. If "Yes," explain.)
NO
YES
17.
DO
YOU HAVE ANY OTHER QUESTIONS OR CONCERN ABOUT YOUR HEALTH? (X one. If "Yes," explain.)
NO
YES
18.
AT THE PRESENT
TIME, DO YOU INTEND TO SEEK DEPARTMENT OF VETERANS AFFAIRS (VA) DISABILITY?
(X one. If "Yes," list conditions for which you will ask for VA Disability.)
NO
YES
UNCERTAIN
19.
CERTIFICATION.
I certify that the information provided above is true and complete to the best of my knowledge.
a.
SIGNATURE OF SERVICE MEMBER
b. DATE SIGNED
DD FORM 2697, FEB 95 (EG)
Designed using Perform Pro, WHS/DIOR, Feb 95
Adobe Professional 7.0
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DD Form 2697 Instructions

The form itself consists of two sections in total. The first section is completed solely by the servicemember and the second one is to be filed by an individually privileged healthcare provider.

  1. Filling out DD Form 2697 starts with completing Boxes 1 through 7 in Section I. These Boxes cover basic credentials, including the name, SSN, rank, component, unit of assignment, home address and telephone number of the soldier filing the form. Dates of the last physical examination and the date of entering current duty must be provided in Boxes 8 and 9 respectively.
  2. Boxes 10 through 18 are multiple choice questions with extra space for a detailed explanation in case there is one needed.
  3. Box 10 requires the servicemember to evaluate their current health status compared to previous medical or physical assessment.
  4. Box 11 is for specifying if there was an absence from duty for longer than three days due to injury or illness since the last medical assessment.
  5. Any hospital stays, surgeries or treatments must be described in Box 12.
  6. Any injury or illness was left untreated during service must be recorded in Box 13.
  7. Box 14 is for describing any current medication intake.
  8. If an illness or injury that may result in assignment limitations or hinder current service must be specified in Box 15.
  9. Box 16 is for acknowledging any dental problems.
  10. Any questions or concerns about health must be stated in Box 17.
  11. Box 18 is for expressing interest and intent to seek Department of Veterans Affairs (VA) disability.
  12. Box 19 is for certification and verifies that the provided information is true and complete. It requires a signature and date of the servicemember filing.
  13. Section II of DD Form 2697 consists of Boxes 20 through 25.
  14. Box 20 is completed in case there are any further comments. 
  15. The need for any further evaluation is expressed in Box 21.
  16. Box 22 is for clarifying the overall purpose of the assessment.
  17. Boxes 23 through 25 are for verification and the required signatures.
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