Dd Form 2796 PDF Details

In the life of military personnel, the period following deployment is critical for assessing and addressing any health concerns that may have arisen during their time overseas. The DD Form 2796, also known as the Post-Deployment Health Assessment (PDHA), serves this very purpose. Designed to be completed electronically to ensure accuracy and efficiency, the form mandates the comprehensive collection of personal health information upon an individual's return from deployment. Underpinned by a clear legal framework, the form is governed by various sections of the United States Code and Department of Defense Instructions, which ensure its authority and the confidentiality of the personal health information it gathers. The primary goal of the DD Form 2796 is to evaluate the overall health of service members after deployment, focusing on identifying issues that may require further medical attention, whether physical, dental, or behavioral. By meticulously documenting personal experiences, exposures, and any incurred injuries or stressors during deployment, the form aids healthcare providers in crafting tailored care plans for each individual. Moreover, it serves as a gateway for possible referrals to specialized services or additional support, ensuring that no concern is left unaddressed. The form's structured questionnaire guides the respondent through various topics, covering basic demographics, deployment details, health status comparisons pre and post-deployment, exposure to potentially traumatic events, and a detailed symptom checklist, among others. Ultimately, the DD Form 2796 embodies a comprehensive approach to post-deployment health assessment, emphasizing the importance of early detection and intervention for the well-being of returning service members.

QuestionAnswer
Form NameDd Form 2796
Form Length10 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 30 sec
Other namesQtrs, mmm, 2008, TBI

Form Preview Example

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?

 

Yes

No

 

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.

Deployer’s total

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

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