DD Form 2766C PDF Details

Patient's identification: a space for mechanical imprint.

Patient's name: Last, First, M.I.

Sex: Male, Female.

Sponsor and ID: relationship to sponsor, status, rank/grade, sponsor's name (last, first, middle initial), dept/service, organization, SSN/ID number and date of birth.

Controlled by: DHA. CUI Category: PRVCY, HLTH.

Updated: 20250320.

QuestionAnswer
Form NameDD Form 2766C
Form Length1 page
Fillable?Yes
Fillable fields150
Avg. time to fill out25 min
EditionMAR 1998
Controlled byDHA
Other namesDD Form 2766C, DD 2766C, DD2766C, DD-2766C, 2766C, DD Form 2766C form, Adult Preventive and Chronic Care Flowsheet
Official sourceDD Form 2766C (MAR 1998)

How to Fill Out DD Form 2766C

DD Form 2766C at a glance

What it is: DD Form 2766C is the Adult Preventive and Chronic Care Flowsheet (Continuation Sheet).

A filled-in DD Form 2766C example: a nurse records a yearly test

DD Form 2766C example filled out, example: a nurse records a yearly test
A clinic nurse fills out the flowsheet for an adult female patient. She lists one test with a yearly frequency and one date in (a). The picture shows her entries; its names and figures are sample values. The clinic stamps the imprint later, so Patient's identification stays empty. Remarks stays empty because the nurse has nothing to add.

How to fill out DD Form 2766C, box by box

Test, frequency and dates

DD Form 2766C example filled out, test, frequency and dates

Under TEST, FREQUENCY and DATES, fill in the test, its frequency and its dates in (a), (b), (c), (d), (e) and (f).

Remarks

DD Form 2766C example filled out, remarks

Use REMARKS for remarks.

Patient's identification

DD Form 2766C example filled out, patient's identification

Use the PATIENT'S IDENTIFICATION space for the mechanical imprint.

Records maintained at

DD Form 2766C example filled out, records maintained at

Fill in RECORDS MAINTAINED AT.

Patient's name and sex

DD Form 2766C example filled out, patient's name and sex

Under PATIENT'S NAME, fill in LAST, FIRST and M.I.

Under SEX, mark MALE or FEMALE.

Relationship to sponsor, status and rank/grade

DD Form 2766C example filled out, relationship to sponsor, status and rank/grade

Fill in RELATIONSHIP TO SPONSOR, STATUS and RANK/GRADE.

Sponsor's name and dept/service

DD Form 2766C example filled out, sponsor's name and dept/service

Fill in SPONSOR'S NAME (Last, First, Middle Initial) and DEPT/SERVICE.

Organization, SSN/ID number and date of birth

DD Form 2766C example filled out, organization, SSN/ID number and date of birth

Fill in ORGANIZATION, SSN/ID NUMBER and DATE OF BIRTH.

Sources

[1] DD Form 2766C (MAR 1998), Adult Preventive and Chronic Care Flowsheet (Continuation Sheet) (the Official source link on this page).

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