Understanding the OHMR 88 form, known officially as the Ohio Military Reserve Report of Medical History, is crucial for individuals seeking to serve in the Ohio Military Reserve. This document serves as a comprehensive health record, detailing an applicant's medical history, current health status, and any medical treatments or consultations received within the last five years. It is designed to glean a complete picture of the applicant's medical background, including any conditions that might affect their ability to serve. The form requires personal information, such as name, social security or identification number, home address, and the specific position the individual is applying for. Additionally, it covers a wide array of health-related queries, from past illnesses, surgeries, and hospital stays to questions about mental health, sensitivity to certain conditions, and even previous rejections from insurance or military service due to medical reasons. The OHMR 88 form is a critical document, ensuring that individuals are physically and mentally fit for service, while also safeguarding the health and safety of the service members. This confidential form also highlights the necessity for accuracy and truthfulness, with a declaration signed by the applicant affirming the veracity of the provided information, as well as consenting to the release of medical records for the application's assessment.
Question | Answer |
---|---|
Form Name | Ohmr Form 88 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | ohmr88 ohmr form 88a |
OHIO MILITARY RESERVE
REPORT OF MEDICAL HISTORY
(THIS INFORMATION IS FOR OFFICIAL AND
1. LAST |
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2. SOCIAL SECURITY OR IDENTIFICATION NO. |
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HOME ADDRESS (No. street or RFD, city or town, State, and ZIP CODE) |
4. POSITION (title, grade) |
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PURPOSE OF EXAMINATION |
6. DATE OF EXAMINATION |
7. EXAMINING FACILITY OR EXAMINER, AND ADDRESS |
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8.STATEMENT OF EXAMINEES PRESENT HEALTH AND MEDICATIONS CURRENTLY USED
9. HAVE YOU EVER (Please cheek each item) |
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10. DO YOU (Please check each item) |
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YES |
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NO |
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(Check each item) |
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YES |
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NO |
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(Check each item) |
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Lived with anyone who had tuberculosis |
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Wear glasses or contact lenses |
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Coughed up blood |
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Have vision in both eyes |
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Bled excessively after injury or tooth extraction |
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Wear a hearing aid |
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Attempted suicide |
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Stutter or stammer habitually |
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Been a sleepwalker |
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Wear a brace or back support |
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11. HAVE YOU EVER HAD OR HAVE NOW (Please check at left of each item) |
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YES |
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NO |
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DON'T |
(Check each item) |
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YES |
NO |
DON'T |
(Check each item) |
YES |
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NO |
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DON'T |
(Check each item) |
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KNOW |
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KNOW |
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KNOW |
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Scarlet fever, erysipelas |
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Cramps in your legs |
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"Trick" or locked knee |
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Rheumatic fever |
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Frequent indigestion |
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Foot trouble |
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Swollen or painful joints |
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Stomach, liver, or intestinal trouble |
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Neuritis |
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Frequent or sever headache |
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Gall bladder trouble or gallstones |
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Paralysis (Including Infantile |
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Dizziness or fainting spells |
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Jaundice or hepatitis |
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Epilepsy or fits |
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Eye trouble |
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Adverse reaction to serum, drug, or |
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Car, train, sea or air sickness |
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medication |
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Ear, nose or throat trouble |
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Broken bones |
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Frequent trouble sleeping |
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Hearing loss |
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Tumor, growth, cyst, cancer |
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Depression or excessive worry |
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Chronic or frequent colds |
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Rupture/hernia |
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Loss of memory or amnesia |
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Severe tooth or gum trouble |
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Piles or rectal disease |
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Nervous trouble of any sort |
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Sinusitis |
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Frequent or painful urination |
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Periods of unconsciousness |
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Hay fever |
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Bed wetting since age 12 |
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Stroke |
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Head injury |
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Kidney stone or blood in urine |
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Diabetes |
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Skin diseases |
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Sugar or albumin in urine |
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Thyroid trouble |
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Tuberculosis |
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Recent gain or loss of weight |
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Asthma |
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Arthritis, Rheumatism or Bursitis |
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Shortness of breath |
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Bone, joint or other deformity |
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Pain or pressure in chest |
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Lameness |
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Chronic cough |
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Loss of finger or toe |
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Palpitation or pounding heart |
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Painful or "trick" shoulder or elbow |
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Heart trouble |
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Recurrent back pain |
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High or low blood pressure |
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12. WHAT IS YOUR USUAL OCCUPATION?
OHMR FORM 88 (JAN 07)
YES NO CHECK EACH ITEM YES OR NO. EVERY ITEM CHECKED YES MUST BE FULLY EXPLAINED IN BLANK SPACE ON RIGHT
13. Have you been refused employment or been unable to hold a job or stay in school because of:
A. Sensitivity to chemicals, dust, sun light, etc.
B. Inability to perform certain motions.
C. Inability to assume certain positions.
D. Other medical reasons (if yes, give reasons)
14. Have you ever been treated for a mental condition? (If yes, specify when, where, and give details.)
15. Have you ever been denied life insurance? (If yes, state reason and give details.)
16. Have you had, or have you been advised to have any operations? (If yes, describe and give age at which occurred.)
17. 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.)
18. Have you ever had any iIIness or injury other than
those already noted? (If yes, specifically when, where, and give details.)
19. 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.)
20. Have you ever been rejected for military service because of physical, mental, or other reasons?
(If yes, give, date and reason for rejection.)
21. Have you ever been discharged from military service because of physical, mental, or other reasons?
(If yes, give date, reason, and type of discharge: whether honorable, other than honorable, for
unfitness or unsuitability.)
22. Have you ever received, is there pending or have you applied for pension or compensation for existing disability? (If yes, specify what kind granted by whom, and what amount, when, why.)
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 doctors, hospitals, or clinics mentioned above to furnish the OHIO MILITARY RESERVE a complete transcript of my medical record for purposes of processing my application for this employment or service.
TYPED OR PRINTED NAME OF APPLICANT:
SIGNATURE:
23. ADDITIONAL COMMENTS:
24. HEIGHT |
25. WEIGHT |
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26. COLOR HAIR |
27. COLOR EYES |
28. BUILD: (CHECK ONE) |
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A. SLENDER |
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B. MEDIUM |
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C. HEAVY |
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29. TEMPERATURE: |
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30. BLOOD PRESSURE: (Arm at Heart Level) |
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31. PULSE: (Arm at Heart Level) |
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32.SITTING
33.RECUMBENT:
34.STANDING (3 MIN)
35.SITTING
36.AFTER EXERCISE
37.2 MIN AFTER
38.RECUMBENT
39.RESPIRATION:
40.BLOOD TYPE:
41.RELIGION:
42.TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER:
43.DATE:
44.SIGNATURE:
45.NUMBER OF ATTACHED SHEETS:
OHMR FORM 88 (JAN 07) REVERSE SIDE