Dd Form 2492 PDF Details

The DD Form 2492, known officially as the DOD Medical Examination Review Board (DODMERB) Report of Medical History, serves a critical role in the assessment of individuals applying to various branches of the United States military, including Service Academies, Reserve Officer Training Corps (ROTC) Scholarship Programs, and the Uniformed Services University of the Health Sciences (USUHS). With a focus on gathering comprehensive medical histories, this form demands honest and detailed responses from applicants to avoid any processing delays. Not merely a formality, the DD Form 2492's thorough evaluation process includes mandatory disclosure of any current or past medical conditions, medication usage, and even surgical histories, alongside more specific inquiries about vision, hearing, mental health, and physical conditions that could affect an applicant's eligibility for service. Consequences of non-disclosure or incomplete information can significantly impede the selection process, emphasizing the form's role in maintaining high standards of health and fitness among prospective military personnel. By requiring a signature for accuracy and completeness, the form also underscores the crucial balance between personal privacy and the need for transparency in medical histories, all while adhering to the Privacy Act and other governing mandates. Through the careful collection and review of such sensitive data, the DD Form 2492 ultimately ensures that only those fully qualified and medically fit are considered for the honor and responsibility of military service.

QuestionAnswer
Form NameDd Form 2492
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdodmerb medical history form, form 2492, dd2492, dd form 2492 fillable

Form Preview Example

 

 

 

DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)

 

 

 

 

OMB No. 0704-0396

 

 

 

 

 

 

 

REPORT OF MEDICAL HISTORY

 

 

 

 

OMB approval expires

 

 

(This information is for official and medically confidential use only and will not be released to unauthorized persons.)

NOV 30, 2009

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 Directorate, Information Management Division, 1155 Defense Pentagon, Washington, DC 20301-1155

(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 Number (SSN) is used for positive identification of records.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. NAME (Last, First, Middle Initial)

 

 

 

 

 

 

 

 

 

2. SOCIAL SECURITY NUMBER

 

3. TELEPHONE NO. (Include area code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. PURPOSE OF EXAMINATION

 

 

5. EXAMINATION FACILITY OR EXAMINER AND ADDRESS (Include ZIP Code)

6. DATE OF EXAMINATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(YYYYMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mark each item "Yes" or "No". EVERY QUESTION MUST BE ANSWERED, OR PROCESSING DELAYS WILL OCCUR. Every "Yes" must be

explained in Block 83, REMARKS, on the back of the form. Mark and explain each item to the best of your ability. Be perfectly honest! Your medical records may be

requested to clarify your medical history.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. HAVE YOU EVER OR DO

 

YES

 

NO

 

 

 

YES

NO

DO YOU

9a. If you wear contact lenses, how many days have they

YOU NOW USE ANY OF

 

 

 

 

Marijuana

 

 

 

8. Wear glasses

 

been removed prior to this examination?

YES

NO

THE FOLLOWING:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amphetamines

 

 

 

 

Alcohol (Amount,

 

 

 

9. Wear contact lenses or

 

Less than 3

 

3 - 20

 

 

21 or over

 

 

 

 

 

 

 

 

frequency, treatment,

 

 

 

corneal eye retainers

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Barbiturates

 

 

 

 

if any)

 

 

 

(If Yes, complete 9a.)

 

Type lens:

 

Hard

 

 

Soft

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cocaine

 

 

 

 

Chemical Inhalants

 

 

 

10. HAVE YOU EVER HAD YOUR VISION IMPROVED BY METHODS OTHER THAN STATED IN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Narcotic Drugs

 

 

 

 

Hallucinogens

 

 

 

QUESTIONS 8 OR 9?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

HAVE YOU EVER HAD OR DO YOU NOW HAVE:

YES

NO

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

11.

Eye trouble (exclude glasses, contact lenses)

 

 

40.

Gallbladder trouble or gallstones

 

 

66. Sleepwalking episodes after age 12

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

Have fluctuating vision or double vision

 

 

41.

Hepatitis (yellow jaundice)

 

 

67. Easily fatigued

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.

Have any allergies

 

 

 

 

 

 

42.

Hemorrhoids or rectal disease

 

 

68. Motion sickness (car, train, sea, or air)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14.

Take any medications regularly

 

 

43.

Black or bloody stools

 

 

69. X-ray or other radiation therapy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15.

Stutter or stammer

 

 

 

 

 

 

44.

Frequent or painful urination

 

 

70. Sensitivity to chemicals, dust, sunlight, etc.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16.

Frequent, severe, or migraine headaches

 

 

45.

Bed wetting after age 12

 

 

71. Learning disabilities or speech problems

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17.

Fainting or dizzy spells

 

 

 

 

 

 

46.

Blood, protein, or sugar in urine

YES

NO

HAVE YOU EVER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18.

Periods of unconsciousness

 

 

 

 

47.

History of diabetes

 

 

72. Been refused employment or been unable to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19.

Head injury or skull fracture

 

 

 

 

48.

Kidney stone

 

 

hold a job or stay in school because of:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20.

Epilepsy, seizures or convulsions

 

 

49.

Hernia or rupture

 

 

a. Inability to perform certain movements?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21.

Loss of memory (AMNESIA)

 

 

 

 

50.

Any bone or joint problem, injuries, surgery

 

 

b. Inability to assume certain positions?

 

 

 

 

 

 

 

 

 

 

 

 

or medical treatment

 

 

 

 

 

 

 

 

 

 

22.

Depression, anxiety, excessive worry, or

 

 

 

 

 

c. Other medical reasons?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

nervousness

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

51.

Steel pins, plates, or staples in any bones

 

 

73. Been rejected for or discharged from military

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

service because of physical, mental or other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23.

Any mental condition or illness

 

 

52.

Wear a bone or joint brace or support

 

 

 

 

 

 

 

 

reasons?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24.

Frequent trouble sleeping

 

 

 

 

53.

Back pain or trouble

 

 

74. Been denied or rated up for life insurance?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25.

Hearing loss

 

 

 

 

 

 

54.

Paralysis or weakness

 

 

75. Received or applied for pension or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

26.

Ear, nose, or throat trouble

 

 

 

 

55.

Foot trouble/use orthotics

 

 

compensation for existing disability?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

27.

Sinusitis or sinus trouble

 

 

 

 

56.

Rheumatic fever

 

 

76. Had or been advised to have, any surgical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28.

Hay fever or allergic rhinitis

 

 

 

 

57.

Tuberculosis or positive TB test

 

 

operations?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29.

Tooth/gum trouble, or current orthodontics

 

 

58.

Sexually transmitted disease (syphilis,

 

 

77. Consulted, or been treated by clinics,

 

 

 

 

 

 

hospitals, physicians, healers, or other

 

 

 

 

 

 

 

 

 

 

 

 

gonorrhea, herpes)

 

 

 

 

30.

Thyroid trouble

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

practitioners for other than minor illnesses?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

31.

Chronic cough or lung disease

 

 

59.

Skin conditions such as acne, psoriasis,

 

 

78. Had any injury or illness other than those

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

32.

Asthma or wheezing

 

 

 

 

 

 

 

hand or foot rashes, eczema, or dry skin

 

 

already noted?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33.

Unusual shortness of breath

 

 

 

 

60.

Adverse reaction to vaccines, drugs,

YES

NO

FEMALES ONLY (Complete Items 79 - 82)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

34.

Pain or pressure in chest

 

 

 

 

 

medicines, foods, insect bites or stings

 

 

79. Been treated for a female disorder, painful

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

35.

Palpitation or pounding heart

 

 

 

 

61.

Eating disorder

 

 

periods, or cramps

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

36.

Heart trouble or heart murmur

 

 

 

 

62.

Recent gain or loss of weight

 

 

80. Had a change in menstrual pattern

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

37.

High blood pressure

 

 

 

 

 

 

63.

Excessive bleeding or easy bruising

 

 

81. Are you now pregnant?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

38.

Coughed up or vomited blood

 

 

 

 

64.

Tumor, growth, cyst, or cancer

 

 

82. Date of last menstrual period (YYYYMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

39.

Stomach, liver, or intestinal trouble

 

 

65.

Considered or attempted suicide

 

 

 

 

 

 

 

 

DD FORM 2492, MAR 2008

 

 

PREVIOUS EDITION IS OBSOLETE.

DoD Exception to SF93 approved by GSA/IRMS (8-91)

Adobe Professional 7.0

83.REMARKS. Applicant use only. Every "yes" response in items 7 through 81 must be explained in the space provided. Give specific dates and details including names of physicians and hospitals or clinics and the current status of the condition. If additional space is required, continue on a separate sheet and attach to this form.

84.CERTIFICATION. I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the physicians, hospitals, or clinics mentioned above to furnish the Government a complete transcript of my medical record for purposes of processing my application for this employment or service.

TYPED OR PRINTED NAME OF EXAMINEE/APPLICANT

SIGNATURE OF EXAMINEE/APPLICANT

DATE SIGNED

(YYYYMMDD)

85.EXAMINER'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA. Examiner shall comment on all "Yes" and blank answers, indicating the item number before each comment. Develop by interview any additional medical history deemed important, and record significant findings here. If additional space is required, continue on a separate sheet and attach to this form.

86. EXAMINER

TYPED OR PRINTED NAME OF EXAMINER

SIGNATURE OF EXAMINER

DATE SIGNED

(YYYYMMDD)

87.NUMBER OF ATTACHED SHEETS

DD FORM 2492 (BACK), MAR 2008

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completing dodmerb physical exam form 2020 stage 1

Write the necessary information in the Depression anxiety excessive, Any bone or joint problem, Steel pins plates or staples in, Any mental condition or illness, Wear a bone or joint brace or, Frequent trouble sleeping, Hearing loss, Ear nose or throat trouble, Sinusitis or sinus trouble, Back pain or trouble, Paralysis or weakness, Foot troubleuse orthotics, Rheumatic fever, Hay fever or allergic rhinitis, and Tuberculosis or positive TB test area.

Completing dodmerb physical exam form 2020 step 2

The software will require you to present particular important data to effortlessly fill out the section REMARKS Applicant use only Every.

stage 3 to completing dodmerb physical exam form 2020

The TYPED OR PRINTED NAME OF, SIGNATURE OF EXAMINEEAPPLICANT, DATE SIGNED YYYYMMDD, EXAMINERS SUMMARY AND ELABORATION, EXAMINER TYPED OR PRINTED NAME OF, SIGNATURE OF EXAMINER, DATE SIGNED YYYYMMDD, and NUMBER OF ATTACHED SHEETS field will be your place to insert the rights and obligations of either side.

Entering details in dodmerb physical exam form 2020 stage 4

Step 3: Choose the Done button to save the file. So now it is ready for export to your gadget.

Step 4: To stay away from probable forthcoming concerns, be sure to possess as much as several copies of any document.

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