DD Form 2795: Pre-Deployment Health Assessment

You are encouraged to answer all questions. You must at least complete the first portion on who you are and when you will deploy. If you do not understand a question, please discuss the question with a health care provider.

Under DEMOGRAPHICS, enter the Last Name, First Name and Middle Initial, the Social Security Number, Today's Date (dd/mmm/yyyy) and the Date of Birth (dd/mmm/yyyy), and mark Male or Female under Sex.

Mark the Service Branch: Air Force, Army, Navy, Marine Corps, Coast Guard, Civilian Expeditionary Workforce (CEW), USPHS or Other Defense Agency, and for Other Defense Agency write it after List. Mark the Component: Active Duty, National Guard, Reserves or Civilian Government Employee. Mark the Pay Grade: E1 to E9, O1 to O10, W1 to W5 or Other.

Under Current contact information, enter your Phone, Cell, DSN, Email and Address. Under Point of contact who can always reach you, enter the Name, Phone, Email and Address.

Enter the Estimated date of upcoming deployment (dd/mmm/yyyy), list the country you are deploying to (if known) and enter the Name of operation (if known).

Mark how many deployments you have done before: None, 1, 2, 3, 4, 5 or 6 or more. If you answered one or more, enter when you returned from your last deployment (Mmm yyyy).

Enter the Deployer's SSN (Last 4 digits).

1. Overall, how would you rate your health during the PAST MONTH? Mark Excellent, Very Good, Good, Fair or Poor.

2. Are you CURRENTLY on a profile, limited duty, waiting on a MOS/Medical Retention Board (MMRB) decision, or being referred to a medical evaluation board (MEB) or physical evaluation board (PEB)? Mark Yes, No or Don't know. For Yes, enter For what reason?

3. How often do you smoke tobacco (for example cigarettes, cigars, pipe or hookah)? Mark Just about every day, Some days or Not at all.

4. What problems, questions or concerns do you have about your medical, dental, or mental health? Enter them after Please explain, or mark None.

5. FEMALES ONLY - Are you pregnant or is there a chance you could be pregnant? Mark Don't know, Yes or No.

6. In the PAST YEAR did you receive care for a head injury? Mark Yes or No. For Yes, enter Please explain.

7. What prescription or over-the-counter medications (including herbals/supplements) for sleep, pain, combat stress, or mental health conditions or concerns are you CURRENTLY taking? Enter them after Please list, or mark None.

8. In the PAST YEAR did you receive care for any mental health condition or concern such as, but not limited to post traumatic stress disorder (PTSD), depression, anxiety disorder, alcohol abuse or substance abuse? Mark Yes or No, and explain a Yes after Please explain.

9. During the PAST MONTH, how much have you been bothered by any of the following problems? For Noises in your head or ears (such as ringing, buzzing, crickets, humming, tone, etc.) and for Trouble hearing, mark Not bothered at all, Bothered a little or Bothered a lot.

10a. How often do you have a drink containing alcohol? Mark Never, Monthly or less, 2-4 times a month, 2-3 times per week or 4 or more times a week. 10b. How many drinks containing alcohol do you have on a typical day when you are drinking? Mark 1 or 2, 3 or 4, 5 or 6, 7 to 9, or 10 or more. 10c. How often do you have six or more drinks on one occasion? Mark Never, Less than monthly, Monthly, Weekly or Daily or almost daily.

11. Have you ever had any experience that was so frightening, horrible, or upsetting that, in the PAST MONTH, you: 11a. Have had nightmares about it or thought about it when you did not want to? 11b. Tried hard not to think about it or went out of your way to avoid situations that remind you of it? 11c. Were constantly on guard, watchful or easily startled? 11d. Felt numb or detached from others, activities, or your surroundings? Mark Yes or No for each. NOTE: If 2 or more items on 11a. through 11d. are marked yes, continue to answer items 11e. through 11v.

Please read each question carefully and check the box for how much you have been bothered by that problem in the PAST MONTH. Please answer all items. For 11e. and the items after it, mark Not at all, A little bit, Moderately, Quite a bit or Extremely.

11v. How difficult have these problems (11e. through 11u) made it for you to do your work, take care of things at home, or get along with other people? Check Not difficult at all, Somewhat difficult, Very difficult or Extremely difficult.

12. Over the LAST 2 WEEKS, how often have you been bothered by the following problems? 12a. Little interest or pleasure in doing things; 12b. Feeling down, depressed, or hopeless. NOTE: If 12a. or 12b. are marked “More than half the days” or “Nearly every day,” continue to answer items 12c. through 12i. For 12a. and 12b., and for 12c. to 12h., mark Not at all, Few or several days, More than half the days or Nearly every day.

12i. How difficult have these problems (12a.through12h.) made it for you to do your work, take care of things at home, or get along with other people? Mark Not difficult at all, Somewhat difficult, Very difficult or Extremely difficult.

13. a. Over the PAST MONTH, what major life stressors have you experienced that are a cause of significant concern or make it difficult for you to do your work, take care of things at home? Mark None or enter them after Please list and explain. b. Are you currently in treatment or getting professional help for this concern? Mark Yes or No.

Health Care Provider Only: Provider Review, Interview, Assessment, and Recommendations.

Recommended referral(s) 12: Within 24 hours, Within 7 days, Within 30 days.

Comments (Mandatory for any type of Not Deployable disposition).

Enter the Provider's Name and the Date (dd/mmm/yyyy), and mark the Title: MD or DO, PA, Nurse Practitioner, Adv Practice Nurse, IDMT, IDC or IDHS.

"I certify that this review process has been completed."