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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

NNUTRITION/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

tTRAVEL

o	OCCUPATIONAL EXPOSURE
	(HEARING THRESHOLD CHANGES/
	(HEARING THRESHOLD CHANGES/	j. DATE
	CUMULATIVE TRAUMA DISORDER)	j. DATE
	CUMULATIVE TRAUMA DISORDER)

		k. AGE
		l. TOPIC

ADVANCE DIRECTIVES: DATE FILED

PATIENT’S IDENTIFICATION (Use this space for mechanical imprint) RECORDS MAINTAINED AT:

	PATIENT’S NAME			SEX
	LAST	FIRST	M.I.
SUPPLIED (Navy)

	RELATIONSHIP TO SPONSOR	STATUS	RANK/GRADE
2766-0102-LF-984-8400, pkg-100	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

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)

	a. TEST	b. FREQUENCY	c. YEAR
	a. TEST	b. FREQUENCY	d. AGE
			d. AGE

(1) CLINICAL DISEASE		ANNUAL		e. DATES
PREV EVAL/PHA (HEAR)

*(2) WEIGHT		ANNUAL FOR ACTIVE DUTY

*(3) HEIGHT		ANNUAL FOR ACTIVE DUTY

*(4) BLOOD PRESSURE		ONCE q 2 YRS FOR BP <
		130/85, ANNUAL IF GREATER
(5) CHOLESTEROL*		*q 5 YRS FOR AGE > 18
		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
(9) EYE/VISION**		ASSESSMENT DIABETES ANNUAL
(9) EYE/VISION**		GLAUCOMA CHECK:
		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
(12)	PAP	SEXUAL ACTIVITY
**(Digital Rectal Exam)		AFTER 3 NL ANNUAL EXAMS,
**(Digital Rectal Exam)		PERFORM q 1-3 years.
		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
(17)	PROSTATE**	WITH P.E. > 40 YRS (Presently
**(DIGITAL RECTAL EXAM)		recommended annually)

(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

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

IMMUNIZATION

(ddmmmyyyy)

IMMUNIZATION

(ddmmmyyyy)

IMMUNIZATION

(ddmmmyyyy)

IMMUNIZATION

(ddmmmyyyy)

a. HEP A #1

f. MMR #1

j. TD (q 10 YRS)

(Last)

b. HEP A #2

g. MMR #2

k. TD (DUE)

c. HEP B #1

l. YELLOW

PNEUMOCOCCUS

FEVER (LAST)

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

o. ANTHRAX

(1) INITIAL DATE

(2) 2 WEEK DATE

(3) 4 WEEK DATE

(4) 6 MONTH DATE

(5) 12 MONTH DATE

(6) 18 MONTH DATE

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

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

s. MENINGO

(1) DATE

(2) DATE

v. OTHER (Specify)

(1) DATE

(2) DATE

(3) DATE

t. ADENO

(1) DATE

(2) DATE

w. OTHER (Specify)

(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

e. PERMANENT PROFILE CHANGE

(1) DATE

(2) P:

(3) U:

(4) L:

(5) H:

(6) E:

(7) S:

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)

h. HIV TESTING

(1) DATE

(2) DATE

(3) DATE

(4) DATE

(5) DATE

(6) DATE

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

(d) DATE

(e) DATE

(f) DATE

(2) POSTDEPLOYMENT

(a) DATE

(b) DATE

(d) DATE

(e) DATE

(f) DATE

b. LOCATION

(1) PREDEPLOYMENT

(a) DATE

(b) DATE

(d) DATE

(e) DATE

(f) DATE

(2) POSTDEPLOYMENT

(a) DATE

(b) DATE

(d) DATE

(e) DATE

(f) DATE

c. CHART AUDIT

DD FORM 2766, (Rev. 01-00)

PAGE 3 of 4 PAGES

ADULT PREVENTION AND CHRONIC CARE FLOWSHEET

(Continuation Sheet)

a. TEST

b. FREQUENCY

DATES

(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

Question	Answer
Form Name	Dd 2766 Army Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	dd form 2766c vaccine administration record, da form 2766, army dd form 2766, dd form 2766c

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