This form must be completed electronically. Handwritten forms will not be accepted.
POST DEPLOYMENT HEALTH ASSESSMENT (PDHA)
PRIVACY ACT STATEMENT
This statement serves to inform you of the purpose for collecting personally identifiable information through the DD Form 2796, Post-Deployment Health Assessment (PDHA).
AUTHORITY:10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 10 U.S.C. 1074f, Medical Tracking System for Members Deployed Overseas; DoDI 1404.10, DoD Civilian Expeditionary Workforce; DoDI 6490.02E, Comprehensive Health Surveillance, and E.O. 9397 (SSN), as amended.
PURPOSE:To obtain information from an individual in order to assess the state of the individual’s health after deployment outside the United States, its territories and possessions as part of a contingency, combat, or other operation and to assist health care providers in identifying and providing present and future medical care to the individual. The information provided may result in a referral for additional health care that may include medical, dental, or behavioral health care or diverse community support services.
ROUTINE USES: Your records may be disclosed to other Federal and State agencies and civilian health care providers, as necessary, in order to provide medical care and
treatment. Use and disclosure of you records outside of DoD may also occur in accordance with 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, which incorporates the DoD “Blanket Routine Uses” published at: http://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html. Any protected
health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD by DoD 6025.18-R. Permitted uses and discloses of PHI include, but are not limited to, treatment, payment, and healthcare operations.
DISCLOSURE:Voluntary. If you chose not to provide information, comprehensive healthcare services may not be possible or administrative delays may occur.
HOWEVER, CARE WILL NOT BE DENIED.
INSTRUCTIONS: You are encouraged to answer all questions. You must at least complete the first portion on who you are and when and where you deployed. If you do not understand a question, please discuss the question with a health care provider.
DEMOGRAPHICS |
|
|
|
|
|
Last Name __________________________ First Name ______________________ |
Middle Initial ____ |
Social Security Number ______________________ |
Today’s Date (dd/mmm/yyyy) ____________________ |
Date of Birth (dd/mmm/yyyy) ___________________ |
Gender Male |
Female |
|
|
Service Branch |
Component |
|
Pay Grade |
|
|
Air Force |
Active Duty |
|
E1 |
O1 |
W1 |
Army |
National Guard |
|
E2 |
O2 |
W2 |
Navy |
Reserves |
|
E3 |
O3 |
W3 |
Marine Corps |
Civilian Government Employee |
E4 |
O4 |
W4 |
Coast Guard |
|
|
E5 |
O5 |
W5 |
Civilian Expeditionary Workforce (CEW) |
|
E6 |
O6 |
|
USPHS |
|
|
E7 |
O7 |
Other |
Other Defense Agency List: _________________ |
|
E8 |
O8 |
|
|
|
|
E9 |
O9 |
|
|
|
|
|
O10 |
|
Home station/unit: _________________________________ |
|
|
Current contact information: |
|
Point of contact who can always reach you: |
Phone: ______________________________ |
|
Name: ________________________________ |
Cell: |
________________________________ |
|
Phone: _______________________________ |
DSN: _______________________________ |
|
Email: ________________________________ |
Email: _______________________________ |
|
Address: ______________________________ |
Address: _____________________________ |
|
______________________________ |
|
_____________________________ |
|
______________________________ |
|
_____________________________ |
|
|
|
PLEASE ANSWER ALL QUESTIONS BASED ON YOUR MOST RECENT DEPLOYMENT |
|
Date arrived theater (dd/mmm/yyyy) ________________ |
Date departed theater (dd/mmm/yyyy) _____________ |
Location of operation |
|
|
|
To what areas were you mainly deployed? |
|
|
|
(Please list all that apply, including the number of months spent at each location.) |
|
|
Country 1 __________________________________________ |
Time at location (months) |
__________________ |
|
Country 2 __________________________________________ |
Time at location (months) |
__________________ |
|
Country 3 __________________________________________ |
Time at location (months) |
__________________ |
|
Country 4 __________________________________________ |
Time at location (months) |
__________________ |
|
Country 5 __________________________________________ |
Time at location (months) |
__________________ |
DD FORM 2796, SEP 2012 |
PREVIOUS EDITION IS OBSOLETE |
Page 1 of 10 Pages |
This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
1.Overall, how would you rate your health during the PAST MONTH?
Excellent Very Good Good Fair Poor
2.Compared to before this deployment, how would you rate your health in general now?
Much better now than before I deployed
Somewhat better now than before I deployed
About the same as before I deployed
Somewhat worse now than before I deployed |
Please explain: |
___________________________________________________ |
Much worse now than before I deployed |
Please explain: |
___________________________________________________ |
3.How often did you smoke tobacco (for example cigarettes, cigars, pipe, or hookah) during your deployment?
|
Just about every day Some days Not at all |
|
|
4. |
Were you wounded, injured, assaulted or otherwise hurt during your deployment? |
Yes |
No |
|
If yes, are you still having any problems or concerns related to this event? |
Yes |
No |
|
If yes, please explain: __________________________________________________________________________________________ |
5. |
During your deployment: |
|
|
|
a. Did you ever feel like you were in great danger of being killed? |
Yes |
No |
|
b. Did you encounter dead bodies or see people killed or wounded during this deployment? |
Yes |
No |
|
c. Did you engage in direct combat where you discharged a weapon? |
Yes |
No |
6.How many times during your deployment did you visit a health care provider for a medical or dental health problem/concern?
|
No visits 1 visit 2-3 visits 4-5 visits 6 or more |
|
|
7. |
During this deployment did you receive care for combat stress or a mental health problem/concern? |
Yes |
No |
|
If yes, please explain: ___________________________________________________________________________________________ |
8. |
During this deployment, did you have to spend one or more nights in a hospital as a patient? |
Yes |
No |
|
Reason/dates: _________________________________________________________________________________________________ |
9.During the PAST MONTH, how difficult have physical health problems (illness or injury) made it for you to do your work or other
regular daily activities?
Not difficult at all Somewhat difficult Very difficult Extremely difficult
10.a. During this deployment, did any of the following events happen to you? (Mark all that apply)
(1) Blast or explosion (e.g., IED, RPG, EFP, land mine, grenade, etc.)? Yes No If yes, please estimate your distance from the closest blast or explosion:
Less than 25 meters (82 feet)
25-50 meters (82-164 feet)
50-100 meters (164-328 feet)
More than 100 meters (328 feet)
(2) |
Vehicular accident/crash (any vehicle including aircraft)? |
Yes |
No |
(3) |
Fragment wound or bullet wound? |
|
|
|
a. Head or neck |
Yes |
No |
|
b. Rest of body |
Yes |
No |
(4) |
Other injury (e.g., sports injury, accidental fall, etc.)? |
Yes |
No |
If yes to any of the above, please explain: ___________________________________________________________________________
10.b. As a result of any of the events in 10.a., did you receive a jolt or blow to your head that IMMEDIATELY resulted in:
(1) |
Losing consciousness (“knocked out”)? |
Yes |
No |
|
If yes, for about how long were you knocked out? |
|
|
|
Less than 5 min 5-30 min more than 30 min |
|
|
(2) |
Losing memory of events before or after the injury? |
Yes |
No |
(3) |
Seeing stars, becoming disoriented, functioning |
|
|
|
differently, or nearly blacking out? |
Yes |
No |
10.c. How many total times during this deployment did you receive a blow or jolt to your head? (only answer if you had a yes to any of the questions on 10a.)
0 1 2 3 more than 3 (list number of times) _____________
DD FORM 2796, SEP 2012 |
Page 2 of 10 Pages |
This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
11. During the PAST MONTH, how much have you been bothered by any of the following problems?
|
Symptom |
Not bothered at all |
Bothered a little |
Bothered a lot |
|
a. |
Stomach pain |
|
|
|
b. |
Back pain |
|
|
|
c. |
Pain in the arms, legs, or joints (knees, hips, etc.) |
|
|
|
d. |
Menstrual cramps or other problems with your periods (Women only) |
|
|
|
e. |
Headaches |
|
|
|
f. |
Chest pain |
|
|
|
g. |
Dizziness |
|
|
|
h. |
Fainting spells |
|
|
|
i. |
Feeling your heart pound or race |
|
|
|
j. |
Shortness of breath |
|
|
|
k. |
Pain or problems during sexual intercourse |
|
|
|
l. |
Constipation, loose bowels, or diarrhea |
|
|
|
m. |
Nausea, gas, or indigestion |
|
|
|
n. |
Feeling tired or having low energy |
|
|
|
o. |
Trouble sleeping |
|
|
|
p. |
Trouble concentrating on things (such as reading a newspaper or watching television) |
|
|
|
q. |
Memory problems |
|
|
|
r. |
Balance problems |
|
|
|
s. |
Noises in your head or ears (such as ringing, buzzing, crickets, humming, tone, etc.) |
|
|
|
t. |
Trouble hearing |
|
|
|
u. |
Sensitivity to bright light |
|
|
|
v. |
Becoming easily annoyed or irritable |
|
|
|
w. |
Fever |
|
|
|
x. |
Cough lasting more than 3 weeks |
|
|
|
y. |
Numbness or tingling in the hands or feet |
|
|
|
z. |
Hard to make up your mind or make decisions |
|
|
|
aa. Watery, red eyes |
|
|
|
bb. Dimming of vision, like the lights were going out |
|
|
|
cc. Skin rash and/or lesion |
|
|
|
dd. Pain with urination, frequency of urination, or strong urge to urinate |
|
|
|
ee. Bleeding gums, tooth pain, or broken tooth |
|
|
|
12. a. Over the PAST MONTH, what major life stressors have |
None or |
|
|
|
you experienced that are a cause of significant concern |
Please list and explain: ___________________________ |
or make it difficult for you to do your work, take care of |
|
|
|
|
|
things at home, or get along with other people (for example, |
______________________________________________ |
serious conflicts with others, relationship problems, |
|
|
|
|
|
or a legal, disciplinary or financial problem)? |
______________________________________________ |
b. Are you currently in treatment or getting professional |
Yes |
No |
|
|
|
help for this concern? |
|
|
|
|
|
|
13. What prescription or over-the-counter medications (including |
Please list: |
____________________________________ |
herbals/supplements) for sleep, pain, combat stress, or a |
|
|
|
|
|
mental health problem are you CURRENTLY taking? |
____________________________________________________ |
|
|
None |
|
|
|
|
14. a. How often do you have a drink containing alcohol? |
|
|
|
|
|
Never Monthly or less |
2-4 times a month 2-3 times per week |
4 or more times a week |
|
|
b. How many drinks containing alcohol do you have on a typical day when you are drinking? |
|
|
1 or 2 3 or 4 5 or 6 |
7 to 9 10 or more |
|
|
|
|
|
c. How often do you have six or more drinks on one occasion? |
|
|
|
|
|
Never Less than monthly |
Monthly Weekly Daily or almost daily |
|
|
|
15. Have you ever had any experience that was so frightening, horrible, or upsetting that, in the PAST MONTH, you: |
|
|
a. Have had nightmares about it or thought about it when you did not want to? |
|
|
Yes |
No |
b. Tried hard not to think about it or went out of your way to avoid situations that remind you of it? |
Yes |
No |
c. Were constantly on guard, watchful or easily startled? |
|
|
|
Yes |
No |
d. Felt numb or detached from others, activities, or your surroundings? |
|
|
|
Yes |
No |
DD FORM 2796, SEP 2012 |
Page 3 of 10 Pages |
This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
16. Over the LAST 2 WEEKS, how often have you been bothered by the following problems?
Not at all Few or several days More than half the days Nearly every day
a. |
Little interest or pleasure in doing things |
|
b. |
Feeling down, depressed, or hopeless |
|
17.Are you worried about your health because you believe you were exposed to something in the environment while deployed?
|
If yes, please explain: ___________________________________________________________________________________________ |
18. |
Do you think you were exposed to any chemical, biological, |
Yes |
No |
|
or radiological warfare agents during this deployment? |
|
|
|
If yes, please explain: __________________________________________________________________________________________ |
19. |
Were you in a vehicle hit by a depleted uranium (DU) round; |
Yes |
No |
|
inside a destroyed vehicle that contained DU; |
|
Don’t know |
|
or closely inspect such a vehicle? |
|
|
|
|
|
If yes, please explain: __________________________________________________________________________________________ |
20. |
Were you told to take medicines to prevent malaria? |
Yes |
No |
|
If yes, please indicate which medicines you took and whether you took all pills as directed. (Mark all that apply) |
|
|
|
Anti-malarial medications received |
Took all pills? |
|
|
|
|
Chloroquine (Aralen®) |
Yes |
No |
|
|
|
|
Doxycycline (Vibramycin®) |
Yes |
No |
|
|
|
|
Malarone® |
Yes No |
|
|
|
|
Mefloquine (Lariam®) |
Yes No |
|
|
|
|
Primaquine |
Yes No |
|
|
|
|
Other: __________________ |
Yes No |
|
|
|
Given pills but do not |
Yes |
No |
|
|
|
|
know drug name |
|
|
|
|
21. |
Were you bitten or scratched by an animal during your deployment? |
Yes |
No |
|
If yes, please explain what kind of animal was involved, your injury, and what happened: |
|
|
|
___________________________________________________________________________________ |
|
|
|
___________________________________________________________________________________ |
|
|
22. |
Would you like to schedule an appointment with a health care provider to discuss any health concern(s)? |
Yes |
No |
23. |
Are you interested in receiving information or assistance for a stress, emotional or alcohol concern? |
Yes |
No |
24. |
Are you interested in receiving assistance for a family or relationship concern? |
Yes |
No |
25. |
Would you like to schedule a visit with a chaplain or a community support counselor? |
Yes |
No |
DD FORM 2796, SEP 2012 |
Page 4 of 10 Pages |
This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
Health Care Provider Only – Provider Review, Interview, Assessment, and Recommendations:
Deployer reports arriving in theater on: _______________________ Deployer reports departing theater on: _______________________
1.Address concerns identified on deployer questions 1 and 2.
|
|
Not |
Deployer |
Deployer’s response |
Provider comments |
|
Deployer question |
indicated |
|
answered |
or concern |
(if indicated) |
|
|
concern |
|
|
|
|
|
|
|
|
Self health rating |
|
|
|
|
|
Change in health post-deployment |
|
|
|
|
2.Address wounds, injuries, assaults, etc., occurring during deployment as reported on deployer question 4.
a. Did deployer mark that he/she is still having a problem |
Yes |
|
or concern related to a wound, injury, or assault that |
No (go to block 3) |
occurred during their deployment? |
Not answered by deployer |
b. Refer for evaluation? |
Yes (complete blocks 19 and 20) |
|
No |
Already under care |
|
|
Already has referral |
No significant impairment
Other reason (explain): _________________________
3.Deployment experiences as reported in deployer question 5. Consider in overall assessment; ask follow-up questions as indicated.
|
|
Not |
Yes |
|
|
Deployer question |
Provider comments (if indicated) |
|
answered |
response |
|
|
|
|
Danger of being killed |
|
|
|
|
|
|
|
|
|
Encountered bodies or saw people killed or wounded |
|
|
|
|
|
|
|
|
|
In direct combat and discharged weapon |
|
|
|
|
|
|
|
|
4.Address concerns identified on deployer questions 6 through 9.
|
|
Not |
Deployer |
Deployer’s response |
|
|
|
|
|
|
|
|
Deployer question |
indicated |
Provider comments (if indicated) |
|
answered |
or concern |
|
|
concern |
|
|
|
|
|
|
|
|
|
|
Health care visits during deployment |
|
|
|
|
|
|
|
|
|
|
|
Care for combat stress/mental health |
|
|
|
|
|
|
|
|
|
|
|
Hospitalized during deployment |
|
|
|
|
|
|
|
|
|
|
|
Physical limitations/problems |
|
|
|
|
|
|
|
|
|
|
5.Deployment injury and concussion risk assessment.
a. Did deployer have an injury based on their |
Yes |
responses to question 10.a.? |
No (go to block 6) |
b. Did deployer have a possible concussion based on |
Yes |
their responses to questions 10.a. through 10.c.? |
No (go to block 6) |
c. Evaluate injury history and concussion-related experiences and symptoms.
Refer for evaluation? |
Yes (complete blocks 19 and 20) |
|
No |
Already under care |
|
|
Already has referral |
No significant impairment
Other reason (explain): ________________________
DD FORM 2796, SEP 2012 |
Page 5 of 10 Pages |
Already under care Already has referral
No significant impairment
Other reason (explain): ________________________
This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
6.Post-deployment general symptoms/health concerns.
List of symptoms reported as “Bothered a Lot” on Deployer Questions 11a. through 11ee.
List of symptoms reported as “Bothered a Little” on Deployer Questions 11a. through 11ee.
Physical symptom (PHQ-15) severity score for Deployer Questions 11a. through 11o.
Minimal < 4 |
Low 5 - 9 |
Medium 10 - 14 |
High ≥ 15 |
_____ |
_____ |
_____ |
_____ |
a. Does deployer have evidence of high generalized post-deployment |
Yes |
|
physical symptoms (a score of ≥ 15 on the PHQ-15 physical |
No |
|
symptoms scale - deployer questions 11a. - 11o.) or is “bothered |
Not answered by deployer |
a lot” by specific symptoms listed in 11a. – 11ee.? |
|
|
b. Based on deployer’s responses to deployer questions |
Yes |
(complete blocks 19 and 20) |
11a. through 11ee. is a referral indicated? |
No |
Already under care |
|
|
Already has referral |
No significant impairment
Other reason (explain): ________________________
7.Major life stressor as reported on deployer question 12.
a.Did deployer mark they have a concern or a difficulty with a major life stressor?
b.If yes, ask additional questions to determine level of problem:
c.Consider need for referral. Referral indicated?
Yes Deployer’s concern: _________________________
No (go to block 8)
Not answered by deployer
________________________________________________________
Yes (complete blocks 19 and 20)
No
8.Self-reported history of prescription or over-the-counter medications as described on deployer question 13.
|
|
|
|
Not |
|
|
Yes |
|
|
|
|
|
|
|
|
Deployer question |
|
|
|
Deployer’s response |
|
|
Provider comments (if indicated) |
|
|
|
|
answered |
|
|
response |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Medications |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
DD FORM 2796, SEP 2012 |
Page 6 of 10 Pages |
Already under care Already has referral
No significant impairment
Other reason (explain): ________________________
Yes
No (go to block 12)
Not answered by deployer
This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
9.Alcohol use as reported in deployer question 14.
a. Deployer’s AUDIT-C screening score was ______. (If score between |
Not answered |
0-4 (men) or 0-3 (women) nothing required, go to block 10). |
|
|
|
Number of drinks per week: _____________ |
Maximum number of drinks per occasion: _____________ |
|
|
|
|
|
Based on the AUDIT-C score and assessment of alcohol use, follow the guidance below:
Alcohol Use Intervention Matrix
|
|
|
AUDIT-C Score |
|
|
|
|
|
|
|
|
|
|
|
|
AUDIT-C Score |
|
|
|
Assess Alcohol Use |
Men |
5 - 7 |
|
|
|
Men and Women |
≥ 8 |
|
|
|
|
Women |
4 - 7 |
|
|
|
|
|
|
|
|
Alcohol use WITHIN recommended limits: |
|
|
|
|
|
|
Men: ≤ 14 drinks per week OR ≤ 4 drinks on any occasion |
Advise patient to stay below |
|
|
|
|
recommended limits |
|
|
|
|
Women: ≤ 7 drinks per week OR ≤ 3 drinks on any occasion |
Refer if indicated for further evaluation |
|
|
|
|
|
|
|
|
AND |
|
|
|
Alcohol use EXCEEDS recommended limits: |
|
|
|
|
|
Conduct BRIEF counseling* |
conduct BRIEF counseling* |
|
|
|
|
|
|
|
Men: > 14 drinks per week or > 4 drinks on any occasion |
AND |
|
|
|
|
Women: > 7 drinks per week or > 3 drinks on any occasion |
consider referral for further evaluation |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
*BRIEF counseling: Bring attention to elevated level of drinking; Recommend limiting use or abstaining; Inform about the effects of alcohol on health; Explore and help/support in choosing a drinking goal; Follow-up referral for specialty treatment, if indicated.
b. Referral indicated for evaluation?
Yes (complete blocks 19 and 20)
No Provide education/awareness as needed. State reason if AUDIT-C score was 8+:
|
Already under care |
|
Already has referral |
|
No significant impairment |
|
Other reason (explain): ________________________ |
10. PTSD screening as reported in deployer question 15. |
|
a. Are two or more of the deployer’s responses |
Yes |
to questions 15a. through 15d. “yes?” |
No (go to block 11) |
|
Not answered by deployer |
b. If yes, ask additional questions to determine extent of problem: _______________________________________________________
c. Consider need for referral. Referral indicated? |
Yes (complete blocks 19 and 20) |
|
No |
Already under care |
|
|
Already has referral |
|
|
No significant impairment |
|
|
Other reason (explain): ________________________ |
11. Depression screening as reported in deployer question 16.
a. Did deployer mark “more than half the days” or “nearly every day” on question 16a. or 16b.?
b. If yes, ask additional questions to determine extent of problem; briefly describe results: _____________________________________
c. Consider need for referral. Referral indicated?
Yes (complete blocks 19 and 20)
No
DD FORM 2796, SEP 2012 |
Page 7 of 10 Pages |
This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
12. Environmental and exposure concern/assessment as reported in deployer questions 17 and 18.
a. Did deployer indicate a worry or possible exposure? Yes No (go to block 13)
If yes, mark deployer’s exposure concern(s) |
Animal bites |
Paints |
Animal bodies (dead) |
Pesticides |
Chlorine gas |
Radar/Microwaves |
Depleted uranium |
Sand/dust |
Excessive vibration |
Smoke from burning trash or feces |
Fog oils (smoke screen) |
Smoke from oil fire |
Garbage |
Solvents |
Human blood, body fluids, body parts, or dead bodies |
Tent heater smoke |
Industrial pollution |
Vehicle or truck exhaust fumes |
Insect bites |
Chemical, biological, radiological warfare agent |
Ionizing radiation |
Other exposures to toxic chemicals or materials, such as |
JP8 or other fuels |
ammonia, nitric acid, etc. Please list: |
Lasers |
|
Loud noises |
|
b. If yes, referral indicated?
Yes (complete blocks 19 and 20)
No (provide risk education)
|
Already under care |
|
Already has referral |
|
No significant impairment |
|
Other reason (explain): ________________________ |
13. Depleted uranium (DU) as reported in deployer question 19. |
|
a. Did deployer mark either “yes” or |
Yes |
“don’t know to questions19? |
No (go to block 14) |
b. If yes, based on details of event and extent |
Yes (complete blocks 19 and 20) |
of exposure is referral to PCM for completion |
No (provide risk education) |
of DD Form 2872 (DU Questionnaire) and |
Already under care |
possible 24-hour urinalysis indicated? |
Already has referral |
|
No significant impairment |
|
Other reason (explain): _______________________ |
14.Malaria prophylaxis review as reported in deployer question 20. Deployer reports having deployed to: _________________________
a.Deployment location required malaria prophylaxis?
b.Did deployer receive anti-malarial prophylaxis AND report compliance?
c.If no, determine need for prophylaxis. Prescription indicated?
15.Animal bite (rabies risk) as reported on deployer question 21.
a.Did deployer mark “yes” on animal bite/scratch?
b.If yes, based on details of event and care received is a referral and/or follow-up indicated?
Note: Rabies incubation period can be months to years. Rabies prophylaxis can begin at anytime.
Yes No (go to block 15)
Yes (go to block 15) No
Yes (complete blocks 19 and 20)
No (briefly state reason): _________________________________
Yes
No (go to block 16)
Yes (complete blocks 19 and 20)
No (provide risk education)
Was appropriately treated
Already under care
Already has referral
Situation was not a risk for rabies
Other reason (explain): _______________________
DD FORM 2796, SEP 2012 |
Page 8 of 10 Pages |
This form must be completed electronically. Handwritten forms will not be accepted.
|
Deployer’s SSN (Last 4 digits): _______________________ |
16. Suicide risk evaluation. |
|
|
a. Ask “Over the PAST MONTH, have you been bothered |
Yes |
|
|
by thoughts that you would be better off dead or of |
No (go to block 17) |
|
hurting yourself in some way?” |
|
|
b. If 16.a. was yes, ask: “How often have you |
Few or several days |
|
been bothered by these thoughts?” |
More than half of the time |
|
|
Nearly every day |
c. |
If 16.a. was yes, ask: “Have you had thoughts of |
Yes (If yes, ask questions 16d. through 16g.) |
|
actually hurting yourself?” |
No (If no thoughts of self-harm, go to block 17) |
d. Ask “Have you thought about how you might actually hurt yourself?” |
Yes How? |
____________________________________ |
|
|
No |
|
e. Ask “There’s a big difference between having a thought and |
Not at all likely |
|
acting on a thought. How likely do you think it is that you will |
Somewhat likely |
|
act on these thoughts about hurting yourself or ending |
Very likely |
|
|
your life over the next month?” |
|
|
f. |
Ask “Is there anything that would prevent or |
Yes What? |
___________________________________ |
|
keep you from harming yourself?” |
No |
|
g. Ask “Have you ever attempted to harm yourself in the past?” |
Yes How? |
____________________________________ |
|
|
No |
|
h.Conduct further risk assessment (e.g., interpersonal conflicts,
social isolation, alcohol/substance abuse, hopelessness, |
Comments: _____________________________________ |
severe agitation/anxiety, diagnosis of depression or other |
|
psychiatric disorder, recent loss, financial stress, |
______________________________________________ |
legal disciplinary problems, or serious physical illness). |
|
i. Does deployer pose a current risk for harm to self? |
Yes (complete blocks 19 and 20) |
|
No |
17. Violence/harm risk evaluation. |
|
a. Ask, “Over the past month have you had thoughts or |
Yes |
concerns that you might hurt or lose control with someone?” |
No (go to block 18) |
If yes, ask additional questions to determine |
|
extent of problem (target, plan, intent, past history) Comments: |
_____________________________________________________ |
b. Does member pose a current risk to others? |
Yes (complete blocks 19 and 20) |
|
No (briefly state reason): _________________________ |
DD FORM 2796, SEP 2012 |
Page 9 of 10 Pages |
This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
18. Deployer issues with this assessment (mark as appropriate):
Deployer declined to complete form
Deployer declined to complete interview/assessment
Assessment and Referral: After review of deployer’s responses and interview with the deployer, the assessment and need for further evaluation is indicated in blocks 19 through 22.
19. Summary of provider’s identified |
|
|
concerns needing referral |
|
Yes |
No |
|
< Mark all that apply> |
|
|
|
a. None Identified |
|
|
|
b. Physical health |
|
|
|
|
|
|
|
c. Dental health |
|
|
|
|
|
|
|
d. Concussion |
|
|
|
|
|
|
|
e. Mental health symptoms |
|
|
|
|
|
|
|
f. Alcohol use |
|
|
|
|
|
|
|
g. PTSD symptoms |
|
|
|
|
|
|
|
h. Depression symptoms |
|
|
|
|
|
|
|
i. Environment/work exposure |
|
|
|
|
|
|
|
j. Depleted uranium |
|
|
|
|
|
|
|
k. Malaria prophylaxis |
|
|
|
|
|
|
|
l. Risk of self-harm |
|
|
|
|
|
|
|
m. Risk of violence |
|
|
|
|
|
|
|
n. Other, list: |
|
|
|
|
|
|
|
|
20. Recommended referral(s) |
|
|
|
|
|
|
|
|
Within |
Within |
Within |
|
< Mark all that apply even if |
|
24 hours |
7 days |
30 days |
|
deployer does not desire> |
|
|
|
|
|
a. Primary Care, Family Practice, |
|
|
|
|
Internal Medicine |
|
|
|
|
|
|
|
|
|
|
b. Behavioral Health in Primary Care |
|
|
|
|
|
|
|
|
|
c. Mental Health Specialty Care |
|
|
|
|
|
|
|
|
|
d. Dental |
|
|
|
|
|
|
|
|
|
e. Other specialty care: |
|
|
|
|
|
|
|
|
|
Audiology |
|
|
|
|
|
|
|
|
|
Dermatology |
|
|
|
|
|
|
|
|
|
OB/GYN |
|
|
|
|
|
|
|
|
|
Physical Therapy |
|
|
|
|
|
|
|
|
|
TBI/Rehab Med |
|
|
|
|
|
|
|
|
|
Podiatry |
|
|
|
|
|
|
|
|
|
Other, list |
|
|
|
|
|
|
|
|
|
f. Case Manager / Care Manager |
|
|
|
|
|
|
|
|
|
g. Substance Abuse Program |
|
|
|
|
|
|
|
|
|
h. Immunization clinic |
|
|
|
|
|
|
|
|
|
i. Laboratory |
|
|
|
|
|
|
|
|
|
j. Other, list: |
|
|
|
|
|
|
|
|
21.Comments: _________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
22. Address requests as reported on deployer questions 22 through 25.
|
|
|
|
|
Not |
|
Yes |
|
|
|
|
|
|
Deployer question |
|
|
|
|
Comments (if indicated) |
|
|
|
|
|
answered |
|
response |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Request medical appointment |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Request info on stress/emotional/alcohol |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Family/relationship concern assistance |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Chaplain/counselor visit request |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
23. Supplemental services recommended / information provided |
|
|
|
|
|
|
|
|
|
|
Appointment Assistance |
|
|
|
|
Family Support |
|
|
|
|
|
Information on post-deployment blood specimen requirement |
|
|
Military One Source |
|
|
|
|
|
Contract Support: _____________________________________ |
|
TRICARE Provider |
|
|
|
|
|
Community Service: ___________________________________ |
|
VA Medical Center or Community Clinic |
|
|
|
Chaplain |
|
|
|
|
|
Vet Center |
|
|
|
|
|
Health Education and Information |
|
|
|
|
Other, list: |
|
|
|
|
|
Health Care Benefits and Resources Information |
|
|
|
|
|
|
|
|
|
|
In Transition |
|
|
|
|
|
|
|
|
|
|
|
|
Provider’s Name: ___________________________________________ |
|
Date (dd/mmm/yyyy) _____________________________ |
Title: MD or DO |
PA |
Nurse Practitioner |
Adv Practice Nurse |
IDMT |
IDC |
IDHS |
I certify that this review process has been completed. |
|
|
|
This visit is coded by V70.5 _ E |
|
|
|
DD FORM 2796, SEP 2012 |
|
|
|
|
|
|
|
|
Page 10 of 10 Pages |
