DA Form 7349 at a glance
What it is: Initial Medical Review, Annual Medical Certificate: for use of this form, see PAM 40-502; the proponent agency is OTSG.
A filled-in DA Form 7349 example: a Soldier completes Part I
How to fill out DA Form 7349, box by box
Tap a group of boxes to open it, and a picture to see it full size.
Part I, the Soldier: the six health questions
Part I is completed by the Soldier, who checks the appropriate response column (YES or NO) for each question.
For the Soldier, number 1: Do you currently have any medical/dental problems?
For the Soldier, number 2: Have you had any medical or dental problems since your last periodic physical examination?
For the Soldier, number 3: Have you been seen by or been treated by a dentist, physician, or other health care provider since your last periodic physical examination?
For the Soldier, number 4: Have you been hospitalized or had surgery since your last periodic physical examination?
For the Soldier, number 5: Are you currently taking medication, or have you taken prescription medication since your last examination?
For the Soldier, number 6: Are you currently or have you in the past received a VA Disability, Workmen's Compensation, or other type of compensation for health or physical reason?
Medications and positive answers
For the Soldier, box 7: list any medications you are currently taking.
For the Soldier, box 8: explain any positive answers given in Part I.
The certification, DoD ID number, name and signature
Certification for the Soldier to sign: I certify that the above information is true and correct to the best of my knowledge. I further understand that false statements made on this form may be cause for reassignment, discharge, or other disciplinary action.
For the Soldier: DoD ID NUMBER (box 9), RANK/GRADE (box 10), MOS (box 11) and DATE (box 12).
For the Soldier: box 13a, PRINTED/TYPED NAME, and box 13b, SIGNATURE (SIGN).
Part II, the Initial Reviewer
Part II is completed by the Initial Reviewer; box 14 is the Initial Reviewer's notes.
Box 15: MEDICALLY READY or REQUIRES FURTHER EVALUATION.
Box 16, SIGNATURE (SIGN), and box 17, DATE.
Part III, the Physician
Part III is completed by the Physician; box 18 is the Physician's review notes.
Box 19: MEDICALLY READY, NOT MEDICALLY READY (USAR refer to para 9-10 & 9-11 AR 40-501), or NOT MEDICALLY READY (Army National Guard refer to MDRB).
Box 20: Complete "PULHES" using the Physical Profile Functional Capacity Guide in Table 7-1, AR 40-501.
Box 21: DA FORM 3349 IS ATTACHED, YES or NO.
Box 22, SIGNATURE (SIGN), and box 23, DATE.
Part IV, the Approving Authority
Part IV is completed by the Approving Authority; box 24 is MISCELLANEOUS RECOMMENDATIONS.
Box 25, SIGNATURE (SIGN), and box 26, DATE.
More rules for DA Form 7349
Authority: Section 133, Title 10, United States Code (10 USC 133).
The primary use of the information is to provide medical information of sufficient detail to ensure uniformity in medical evaluation; it is used to evaluate Soldiers in terms of medical conditions and physical defects which may require medical care or which may require a determination of medical readiness.
The DoD Blanket Routine Uses may apply to this collection.
The requested information is voluntary; if it is not furnished, comprehensive health care may not be possible, but CARE WILL NOT BE DENIED.
Sources
[1] DA Form 7349 (JUN 2019), Initial Medical Review, Annual Medical Certificate, Department of the Army (the Official source link on this page).