Medical Form 2807 PDF Details

Are you a first-time medical patient struggling to understand the paperwork associated with your healthcare provider? One of the most important forms that will come up during your appointments is Medical Form 2807. This form indicates whether or not an individual has been diagnosed by a physician and it provides important information regarding diagnosis, prescribed medications, allergens and other relevant details. Read on to learn more about Medical Form 2807: what it is and why it's essential for successful treatment.

QuestionAnswer
Form NameMedical Form 2807
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesdd 2807, dd form 2807 1 army pubs, report medical history blank, form report medical history

Form Preview Example

REPORT OF MEDICAL HISTORY

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

OMB No. 0704-0413 OMB approval expires September, 30 2021

The public reporting burden for this collection of information is estimated to average 10 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 the burden estimate or burden reduction suggestions to the Department of

Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. 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 AS INDICATED ON PAGE 2.

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 136, Under Secretary Of Defense For Personnel And Readiness; DoD Directive 1145.2, United States Military Entrance Processing Command; DoD Instruction 6130.03, Medical Standards for Appointment, Enlistment, or Induction in the Military Services; and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): The primary collection of this information is from individuals seeking to join the Armed Forces. The information collected on this form is used to assist DoD physicians in making determinations as to acceptability of applicants for military service and verifies disqualifying medical condition(s) noted on the prescreening form (DD 2807-2). An additional collection of information using this form occurs when a Medical Evaluation Board is convened to determine the medical fitness of a current member and if separation is warranted.

ROUTINE USE(S): The Routine Uses are listed in the applicable system of records notice found at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570661/ a0601-270-usmepcom-dod/

DISCLOSURE: Voluntary; however, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application to enter the Armed Forces. An applicant's SSN is used during the recruitment process to keep all records together and when requesting civilian medical records. For an Armed Forces member, failure to provide the information may result in the individual being placed in a non-deployable status. The SSN of an Armed Forces member is to ensure the collected information is filed in the proper individual's record.

WARNING: The information you have given constitutes an official statement. Federal law provides severe penalties (up to 5 years confinement or a $10,000 fine or both), to anyone making a false statement.

1. LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX)

2.a. SOCIAL SECURITY NO.

b.DoD ID NO. (If applicable)

3.TODAY'S DATE (YYYYMMDD)

4.a. HOME ADDRESS (Street, Apartment No., City, State, and ZIP Code)

5. EXAMINING LOCATION AND ADDRESS (Include ZIP Code)

b.HOME TELEPHONE (Include Area Code)

c. EMAIL ADDRESS

X ALL APPLICABLE BOXES:

 

 

 

 

7.a. POSITION (Title, Grade, Component)

6.a. SERVICE

Coast

b. COMPONENT

c. PURPOSE OF EXAMINATION

 

 

Army

 

 

Regular

 

Retention

 

Other (Specify)

 

 

 

Guard

 

 

 

 

 

Navy

 

 

Reserve

 

Separation

 

 

b. USUAL OCCUPATION

 

Marine Corps

 

 

National Guard

 

Medical Board

 

 

 

 

 

 

 

 

 

 

 

Air Force

 

 

 

 

Retirement

 

 

 

 

 

 

 

 

 

 

 

8.

CURRENT MEDICATIONS (Prescription and Over-the-counter)

9. ALLERGIES (Including insect bites/stings, foods, medicine or other substance)

Mark each item "YES" or "NO". Every item marked "YES" must be fully explained in Item 29 on Page 2.

HAVE YOU EVER HAD OR DO YOU NOW HAVE:

 

YES NO

 

12. (Continued)

YES NO

10.a. Tuberculosis

 

 

 

f. Foot trouble (e.g., pain, corns, bunions, etc.)

 

b. Lived with someone who had tuberculosis

 

 

 

g. Impaired use of arms, legs, hands, or feet

 

 

 

 

 

 

 

c. Coughed up blood

 

 

 

h. Swollen or painful joint(s)

 

d. Asthma or any breathing problems related to exercise, weather,

 

 

 

i.

Knee trouble (e.g., locking, giving out, pain or ligament injury, etc.)

 

pollens, etc.

 

 

 

 

 

 

 

 

 

 

e. Shortness of breath

 

 

 

j. Any knee or foot surgery including arthroscopy or the use of a scope

 

 

 

 

 

to any bone or joint

 

f. Bronchitis

 

 

 

k.

Any need to use corrective devices such as prosthetic devices, knee

 

 

 

 

 

brace(s), back support(s), lifts or orthotics, etc.

 

 

 

 

 

 

 

g. Wheezing or problems with wheezing

 

 

 

l. Bone, joint, or other deformity

 

h. Been prescribed or used an inhaler

 

 

 

m. Plate(s), screw(s), rod(s) or pin(s) in any bone

 

 

 

 

 

 

 

i. A chronic cough or cough at night

 

 

 

n. Broken bone(s) (cracked or fractured)

 

j. Sinusitis

 

 

 

13.a. Frequent indigestion or heartburn

 

k. Hay fever

 

 

 

b. Stomach, liver, intestinal trouble, or ulcer

 

l. Chronic or frequent colds

 

 

 

c. Gall bladder trouble or gallstones

 

11.a. Severe tooth or gum trouble

 

 

 

d. Jaundice or hepatitis (liver disease)

 

b. Thyroid trouble or goiter

 

 

 

e. Rupture/hernia

 

 

 

 

 

 

 

c. Eye disorder or trouble

 

 

 

f. Rectal disease, hemorrhoids or blood from the rectum

 

d. Ear, nose, or throat trouble

 

 

 

g. Skin diseases (e.g. acne, eczema, psoriasis, etc.)

 

 

 

 

 

 

 

e. Loss of vision in either eye

 

 

 

h. Frequent or painful urination

 

f. Worn contact lenses or glasses

 

 

 

i. High or low blood sugar

 

 

 

 

 

 

 

g. A hearing loss or wear a hearing aid

 

 

 

j. Kidney stone or blood in urine

 

h. Surgery to correct vision (RK, PRK, LASIK, etc.)

 

 

 

k. Sugar or protein in urine

 

 

 

 

 

 

 

 

12.a. Painful shoulder, elbow or wrist (e.g. pain, dislocation, etc.)

 

 

l.

Sexually transmitted disease (syphilis, gonorrhea, chlamydia, genital

 

 

 

 

warts, herpes, etc.)

 

b. Arthritis, rheumatism, or bursitis

 

 

 

14.a. Adverse reaction to serum, food, insect stings or medicine

 

c. Recurrent back pain or any back problem

 

 

 

b. Recent unexplained gain or loss of weight

 

d. Numbness or tingling

 

 

 

c. Currently in good health (If no, explain in Item 29 on Page 2.)

 

 

 

 

 

 

e. Loss of finger or toe

 

 

 

d. Tumor, growth, cyst, or cancer

 

DD FORM 2807-1 OCT 2018

DoD exception to SF 93 approved by ICMR, August 3, 2000.

Page 1 of 3 Pages

 

PREVIOUS EDITION IS OBSOLETE.

 

 

Adobe Professional XI

LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX)

SOCIAL SECURITY NUMBER

DoD ID NUMBER (If applicable)

Mark each item "YES" or "NO". Every item marked "YES" must be fully explained in Item 29 below.

 

HAVE YOU EVER HAD OR DO YOU NOW HAVE:

YES NO

YES NO

15.a. Dizziness or fainting spells

b.Frequent or severe headache

c.A head injury, memory loss or amnesia

d.Paralysis

e.Seizures, convulsions, epilepsy or fits

f.Car, train, sea, or air sickness

g.A period of unconsciousness or concussion

h.Meningitis, encephalitis, or other neurological problems 16.a. Rheumatic fever

b.Prolonged bleeding (as after an injury or tooth extraction, etc.)

c.Pain or pressure in the chest

d.Palpitation, pounding heart or abnormal heartbeat

e.Heart trouble or murmur

f.High or low blood pressure

17.a. Nervous trouble of any sort (anxiety or panic attacks)

b.Habitual stammering or stuttering

c.Loss of memory or amnesia, or neurological symptoms

d.Frequent trouble sleeping

e.Received counseling of any type

f.Depression or excessive worry

g.Been evaluated or treated for a mental condition

h.Attempted suicide

i.Used illegal drugs or abused prescription drugs

18.FEMALES ONLY. Have you ever had or do you now have:

a.Treatment for a gynecological (female) disorder

b.A change of menstrual pattern

c.Any abnormal PAP smears

d.First day of last menstrual period (YYYYMMDD)

e.Date of last PAP smear (YYYYMMDD)

19.Have you been refused employment or been unable to hold a job or stay in school because of:

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

b.Inability to perform certain motions

c.Inability to stand, sit, kneel, lie down, etc.

d.Other medical reasons (If yes, give reasons.)

20.Have you ever been treated in an Emergency Room? (If yes, for what?)

21.Have you ever been a patient in any type of hospital? (If yes, specify when, where, why, and name of doctor and complete address of hospital.)

22.Have you ever had, or have you been advised to have any operations or surgery? (If yes, describe and give age at which occurred.)

23.Have you ever had any illness or injury other than those already noted? (If yes, specify when, where, and give details.)

24.Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the past 5 years for other than minor illnesses? (If yes, give complete address of doctor, hospital, clinic, and details.)

25.Have you ever been rejected for military service for any reason? (If yes, give date and reason for rejection.)

26.Have you ever been discharged from military service for any reason? (If yes, give date, reason, and type of discharge; whether honorable, other than honorable, for unfitness or unsuitability.)

27.Have you ever received, is there pending, or have you ever applied for pension or compensation for any disability

or injury? (If yes, specify what kind, granted by whom, and what amount, when, why.)

28.Have you ever been denied life insurance?

29.EXPLANATION OF "YES" ANSWER(S) (Describe answer(s), give date(s) of problem, name of doctor(s) and/or hospital(s), treatment given and current medical status.)

NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL PERSONNEL ONLY."

DD FORM 2807-1 OCT 2018

Page 2 of 3 Pages

LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX)

SOCIAL SECURITY NUMBER

DoD ID NUMBER (If applicable)

30.EXAMINER'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician/practitioner shall comment on all positive answers in questions 10 - 29. Physician/practitioner may develop by interview any additional medical history deemed important, and record any significant findings here.)

a. COMMENTS

b. TYPED OR PRINTED NAME OF EXAMINER (Last, First, Middle Initial)

c. SIGNATURE

d. DATE SIGNED

 

 

(YYYYMMDD)

 

 

 

DD FORM 2807-1 OCT 2018

 

Page 3 of 3 Pages

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1. Firstly, when filling out the dd 2807 1, start with the section that has the subsequent blanks:

Completing segment 1 in form report medical history online

2. Just after completing this step, head on to the next part and fill out the essential details in all these fields - Mark each item YES or NO Every, b Lived with someone who had, pollens etc, e Shortness of breath f Bronchitis, a Severe tooth or gum trouble, b Thyroid trouble or goiter c Eye, a Painful shoulder elbow or wrist, b Arthritis rheumatism or bursitis, f Foot trouble eg pain corns, to any bone or joint, braces back supports lifts or, l Bone joint or other deformity m, a Frequent indigestion or heartburn, b Stomach liver intestinal trouble, and warts herpes etc.

Tips on how to fill in form report medical history online portion 2

3. The following segment should also be fairly straightforward, b Arthritis rheumatism or bursitis, DD FORM OCT, b Recent unexplained gain or loss, DoD exception to SF approved by, PREVIOUS EDITION IS OBSOLETE, and Page of Pages Adobe Professional - all of these blanks needs to be filled in here.

form report medical history online completion process shown (stage 3)

It's easy to make errors while filling in the b Arthritis rheumatism or bursitis, and so be sure to take another look before you decide to send it in.

4. The next subsection comes with these particular form blanks to fill out: LAST NAME FIRST NAME MIDDLE NAME, SOCIAL SECURITY NUMBER, DoD ID NUMBER If applicable, Mark each item YES or NO Every, YES NO, Have you been refused employment, YES NO, b Frequent or severe headache c A, a Rheumatic fever, b Prolonged bleeding as after an, a Nervous trouble of any sort, b Habitual stammering or, or stay in school because of a, Have you ever been treated in an, and If yes for what.

Part # 4 for filling in form report medical history online

5. This very last stage to complete this form is pivotal. Be certain to fill in the mandatory blanks, and this includes b Habitual stammering or, FEMALES ONLY Have you ever had or, a Treatment for a gynecological, Have you ever been discharged, reason If yes give date reason and, Have you ever received is there, applied for pension or, Have you ever been denied life, EXPLANATION OF YES ANSWERS, and status, before finalizing. Neglecting to do so may generate an incomplete and probably unacceptable paper!

Guidelines on how to fill in form report medical history online part 5

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