Dd Form 2351 PDF Details

Embarking on the journey to serve in a United States Service Academy, Reserve Officer Training Corps (ROTC) Scholarship Program, or the Uniformed Services University of the Health Sciences requires completion of various prerequisites, one of which includes the essential DD 2351 form. Known as the DOD Medical Examination Review Board (DODMERB) Report of Medical Examination, this document serves as a critical step in determining applicants' medical eligibility to join the esteemed ranks of the military. With a collection of items designed to evaluate an applicant's physical and mental health, the form is meticulously structured to cover an exhaustive array of medical aspects from visual and auditory acuity to cardiovascular health and beyond. As outlined by the Privacy Act Statement, the form not only seeks to confirm the medical readiness of future military personnel but also ensures the privacy and protection of applicants’ personal information, making its completion a task of both significance and sensitivity. With the approach of its expiration on September 30, 2006, individuals are reminded of the importance of carefully reading the instructions and accurately completing the form to facilitate a smooth application process. The DD 2351 form, therefore, stands not just as a mere procedural requirement but as a fundamental gateway to furthering one's commitment to serving their country.

QuestionAnswer
Form NameDd Form 2351
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmedical exam form pdf, doctors exam form, pcv medical form, physical exam form

Form Preview Example

DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)

Form Approved

REPORT OF MEDICAL EXAMINATION

OMB No. 0704-0396

(Please read Privacy Act Statement before completing this form.)

Expires Sep 30, 2006

The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0396). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO DODMERB/DR, 8034 EDGERTON DRIVE, SUITE 132, USAF ACADEMY CO 80840-2200.

PRIVACY ACT STATEMENT

AUTHORITY: Title 10, USC 133, 3012, 5031, 8013, and Executive Order 9397.

PRINCIPAL PURPOSE: To determine medical acceptability or update a medical file as part of the application process to a United States Service Academy, Reserve Officer Training Corps (ROTC) Scholarship Program, or the Uniformed Services University of the Health Sciences (USUHS).

ROUTINE USES: This information may be disclosed to the Coast Guard Academy and Merchant Marine Academy for applications to their Academies.

DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection process and hamper your candidacy. Use of the Social Security Account Number (SSN) is used for positive identification of records.

DODMERB USE ONLY

APPLICANT DATA

1. DATE OF EXAMINATION (YYYYMMDD)

2.NAME (Last, First, Middle Initial)

3. SOCIAL SECURITY ACCOUNT NUMBER

4. DATE OF BIRTH (YYYYMMDD)

5. AGE

6. SEX

7.RACE (Ethnic Group)

8.ADDRESS INFORMATION (If left blank will delay processing) A. APPLICANT MAILING ADDRESS (Include ZIP Code)

9. STATUS (X one)

 

ACTIVE DUTY

 

CIVILIAN

 

RESERVE/GUARD

 

 

 

 

 

 

10.EXAMINER ADDRESS (Street, City, State and Zip Code)

B. ROTC DETACHMENT CODE (If applicable):

MEASUREMENTS

11. HEIGHT (to nearest

 

12. BLOOD PRESSURE

13. AUDIOMETER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. READING ALOUD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TEST

1/4 inch)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SYSTOLIC DIASTOLIC

 

 

500

1000

 

2000

 

3000

4000

 

6000

 

500

 

1000

2000

3000

 

4000

6000

 

 

 

SATISFACTORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STANDING

 

SITTING

 

 

 

 

 

/

 

 

RIGHT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEFT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNSATISFACTORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Explain in Item 57)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. PULSE

 

 

 

 

 

 

17. DISTANT VISION

 

18. REFRACTION

 

 

 

MANIFEST

 

 

 

CYCLO

 

 

 

BY LENS

 

19. NEAR VISION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RIGHT 20/

 

 

CORR TO 20/

 

SPH

 

 

CYL

 

 

 

AXIS

 

 

 

 

20/

 

 

CORR TO 20/

 

BY

16. WEIGHT (to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

nearest pound)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEFT 20/

 

 

CORR TO 20/

 

SPH

 

 

CYL

 

 

 

AXIS

 

 

 

 

20/

 

 

CORR TO 20/

 

BY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. HETEROPHORIA/TROPIA

 

21. COVER TEST

 

22. COLOR VISION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23. DEPTH PERCEPTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Far only)

 

 

 

 

 

 

 

 

 

 

TEST USED

RESULTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TEST USED

 

 

SCORE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ESO

 

 

EXO

 

 

RH

 

 

 

LH

 

 

 

 

PASS

 

 

PIP

NO. PASSED

 

 

 

NO. FAILED

 

 

 

 

 

 

 

 

VTA-ND/OVT/AFVT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Non-Tropia)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FALANT

NO. PASSED

 

 

 

NO. FAILED

 

 

 

 

 

 

 

 

DPA-V

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FAIL (Tropia)

 

 

OTHER (Specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TITMUS/STEREO FLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Arcs per second)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24. NEAR POINT OF CONVERGENCE

 

 

 

 

25. VIVID RED/GREEN (If fail Item 22)

26. OCULAR MOTILITY AND BINOCULARITY (RED LENS TEST)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PASS

 

 

FAIL

 

 

 

PASS

 

 

FAIL

 

IF FAILED:

 

 

DIPLOPIA

 

 

 

SUPPRESSION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LABORATORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

27.URINALYSIS PROTEIN SUGAR

BLOOD

LEUKOCYTE

ESTERASE

 

NEG

 

T

 

1+

 

2+

 

3+

 

4+

 

 

 

 

 

 

 

 

 

 

 

 

 

NEG

 

T

 

1+

 

2+

 

3+

 

4+

 

 

 

 

 

 

 

 

 

 

 

 

 

NEG

 

T

 

1+

 

2+

 

3+

 

4+

 

 

 

 

 

 

 

 

 

 

 

 

 

NEG

 

T

 

1+

 

2+

 

3+

 

4+

 

 

 

 

 

 

 

 

 

 

 

 

MICROSCOPIC EXAMINATION (If required) (X one)

NEGATIVE

POSITIVE

(List results)

28.OTHER TESTS (Specify type and results)

DD FORM 2351, MAR 2004

PREVIOUS EDITION IS OBSOLETE.

DoD Exception to SF 88 Approved by GSA/OIRM 4-88

CLINICAL EVALUATION

NORMAL

 

(X each item in the appropriate column.

ABNOR-

NORMAL

 

 

(X each item in the appropriate column.

ABNOR-

 

Enter "NE" if not evaluated)

 

MAL

 

 

Enter "NE" if not evaluated)

MAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29.

HEAD, FACE, NECK AND SCALP

 

 

 

43.

ABDOMEN AND VISCERA (Include hernia)

 

 

 

 

 

 

 

 

 

 

 

 

30.

NOSE

 

 

 

44.

ENDOCRINE SYSTEM

 

 

 

 

 

 

 

 

 

 

 

 

31.

SINUSES

 

 

 

45.

SPINE, OTHER MUSCULOSKELETAL

 

 

 

 

 

 

 

 

 

 

 

 

32.

MOUTH AND THROAT

 

 

 

46.

UPPER EXTREMITIES (Strength, sensation,

 

 

33.

EARS - GENERAL(Internal and external canals)

 

 

 

range of motion)

 

 

 

 

 

 

 

 

 

 

 

(Auditory acuity under item 13)

 

 

 

47.

LOWER EXTREMITIES (Except feet) (Strength,

 

 

 

 

 

 

 

 

 

34.

DRUMS (Perforation)

 

 

 

 

sensation, range of motion)

 

 

 

 

 

 

 

 

 

 

 

 

35.

VALSALVA

 

 

 

48.

FEET

 

 

 

 

 

 

 

 

 

 

 

 

36.

EYES - GENERAL (Visual acuity and refraction

 

 

49.

IDENTIFYING BODY MARKS, SCARS, TATTOOS

 

 

 

under items 17, 18, and 19)

 

 

 

50.

SKIN, LYMPHATICS

 

 

 

 

 

 

 

 

 

 

 

 

37.

PUPILS (Equality and reaction)

 

 

 

51.

GU SYSTEM

 

 

 

 

 

 

 

 

 

 

 

 

38.

OCULAR MOTILITY (Associated parallel

 

 

 

52.

ANUS AND RECTUM (Hemorrhoids, fistulae)

 

 

 

movements, nystagmus)

 

 

 

 

(Prostate if indicated) EXTERNAL EXAM

 

 

 

 

 

 

 

 

 

 

 

 

39.

OPHTHALMOSCOPIC

 

 

 

53.

FEMALE GU EXTERNAL VISUAL EXAM

 

 

 

 

 

 

 

 

 

 

 

 

40.

LUNGS AND CHEST (Include breasts)

 

 

 

54.

NEUROLOGIC

 

 

 

 

 

 

 

 

 

 

 

 

41.

HEART (Thrust, size, rhythm, and sounds)

 

 

55.

PSYCHIATRIC (Specify any personality deviation)

 

 

 

 

 

 

 

 

 

 

 

 

 

42.

VASCULAR SYSTEM (Varicosities, etc.)

 

 

 

 

 

 

 

 

56. REPEAT BP OR PULSE EXAM (SITTING) IF BP >140/90 OR PULSE >100

 

 

 

 

 

 

 

 

 

 

57. NOTES (Describe every abnormality in detail. Enter the item number before each comment.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

58. EXAMINER (If performed by PA, PCNP, OR FNP)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPED OR PRINTED NAME

RANK

 

CORPS OR DEGREE

 

SIGNATURE

 

 

 

 

 

 

 

 

 

 

59. PHYSICIAN (MD/DO)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPED OR PRINTED NAME

RANK

 

DEGREE

 

 

SIGNATURE

 

DD FORM 2351 (BACK), MAR 2004