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507-109

NSN 7540-00-634-41 20

Report On

MEDICAL RECORD continuation of S.F.

(Strike out one line) (specify type of examination or data)

Date:Addendum to Medical History (SF 93)

Health History Questionsllnterval History

Please circle the correct response for each question

1.	Have you recently had any medical problems or symptoms that bother you?		Yes	No
2. Do any of the following diseases run in your family (parents, grandparents, or siblings)? Cancer, Diabetes, and heart
attacksoranginapriortoage55		. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
3.	Do you have jobs or hobbies which involve exposure to chemicals, dust, or loud noises?		Yes	No
4.	Do you routinely forget to wear proper protective gear for sports or hobbies? (e.g. helmets, goggles, ear plugs, gloves,
etc			.Yes	No
5.	Do you routinely forget to fasten your seatbelt?		Yes	No
6.	Do you exercise less than 3 times per week (at least 20 minutes a session)?		Yes	No
7.	In the past year have you been counseled on the risks and prevention of sexually transmitted diseases?		Yes	No	.
8.	Do you currently (or within the past 2 years) use tobacco products?		Yes	No
9.	Do you have more than one alcoholic drink per day?	. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
10. Have you, or anyone you know, thought you should cut down on your drinking?			Yes	No
11. Do you take prescription medications, over the counter drugs, or nutritional supplements to include herbs?			Yes	No
12. Do you eat more than one serving of high fat or cholesterol (e.g. red meat, eggs, cheese, chocolate, fried foods, milk,
etc...	)p erday?	. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
13. Do you eat fewer than 5 servings of fruits or vegetables each day?			Yes	No
14. Do you feel significantly stressed by your job or life events?			Yes	No
15. Do you feel you have serious problems dealing with your spouse, parents, children, or friends?			Yes	No
16. In the past few months have you been bothered by feeling down, helpless, panicky, or anxious?			Yes	No
17. Have you ever had surgery to correct your vision?			Yes	No
18. Since your last exam dated		have you:
	a. Hadanybrokenbones?		Yes	No
	b. Had any allergic reactions to food or medications?		Yes	No
	c. Been hospitalizedfor at least 24 hours or more?	. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
	d. Had any outpatient surgical procedures done (wisdom teeth, tonsillectomy, cyst removal)?		Yes	No
	e. Been diagnosed with any medical condition that requires any special or continuous treatment?
	Please explain all "yes" answers (diagnosis, date, cause, treatment):		Yes	No

f.Other than the items listed above, please list any other medical treatment or evaluation since your last examination.

19.To the best of my knowledge, NO INO OTHER significant medical or surgical history has occured since my last examination.

Patient Signature:

Examinee denies and medical record review reveals no other significant medical history since last exam dated

Physicians / Sr. Medical

Technician Signature:

(continue on reverse side)

PATIENT'S IDENTIFICATION (For typed or written entries g qEGISTER NO.			WARD NO.
Name-last, first, middle; grade; rank; rate; hospital orTmedical facility)			WARD NO.

Name		REPORT ON	OR CONTINUATION OF
SSAN		REPORT ON	OR CONTINUATION OF
SSAN
Rank1Grade	Sex	DOB	Medical Record
Unit			STANDARD FORM 507 (08-01)
			Prescribed by GSAICIMR, FlRMR (41-CFR) 201-9.202-1
			(Computer generated by Pimr)

Procedures for Completing the SF507

PLEASE READ, DO NOT ANSWER ON THIS FORM

Dear 157th ARW Member,

Since the implementation of the PHA process and SF 507 we have noticed that required medical information has been left off the SF 507. In an effort to ensure that the SF 507 is completed accurately and with the appropriate information, we have developed this form to help you complete the SF 507. Please use it as you complete your SF 507. If you have any questions or concerns regarding this matter, please feel free to contact the Medical Group at X2340. Thank you for your help and cooperation

1.When you answer with a positive response (yes) to any question on the SF507 you are required to supply the appropriate information listed in the action section for each question.

2.Please explain all positive response (yes) answers on the back of the SF507, by placing the question number in front of each explanation.

	QUESTION	IF YES:	ACTION

1	Have you recently had any medical problem or symptoms that bother	State medical problem and symptoms.
	you?

2	Do any of the following diseases run in your family? Cancer,	List the disease and state the relationship of
	Diabetes, and heart attacks or angina prior to age 55.	the person who has the disease to you.

3	Do you have job or hobbies, which involve exposure to chemicals,	List the job/hobbies also list what you are
	dust, or loud noise?	exposed to.

4	Do you routinely forget to wear proper protective gear for sports or	List the names of sports/ hobbies.
	hobbies?

5	Do you routinely forget to fasten your seatbelt?	Yes or No answer

6	Do you exercise less than 3 times per week? ( at least 20 minutes a	Yes or No answer
	session)

7	In the past year have you been counseled on the risks and	State if counseling was a preventive health/
	prevention of sexually transmitted diseases?	pre-deployment briefing or a follow up to
		treatment.
8	Do you currently (or within the past 2 years) use tobacco products?	State the type of tobacco product you use; the
		amount per day you use, and how long you
		have been using.

9	Do you have more than one alcoholic drink per day?	State how many alcoholic drinks you consume
		per day.

10	Have you, or anyone you now, thought you should cut down on your	Briefly explain.
	drinking?

11	Do you take prescription medication, over the counter drugs or	List the name of the medication/supplement
	nutritional supplements to include herbs?	and what it is taken for. Give the amount taken
		and how often taken.

12	Do you eat more than one serving of high fat or cholesterol per day?	Yes or No answer.

13	Do you eat fewer than 5 servings of fruits or vegetables each day?	Yes or No answer.

14	Do you feel you have a high stress job or life style?	Briefly explain.

15	Do you feel you have serious problems dealing with your spouse,	Briefly explain.
	parents, children or friends?

16	In the past few months have you been bothered by feeling down,	Briefly explain.
	helpless, panicky, or anxious?

17	Have you ever had surgery to correct your vision?	State when and where surgery was done.

18	Since your last exam have you?	a. List bone broken and when
		b. List allergy and reaction
		c. List reason for hospitalization and when
		d. list procedure and when.
		e. List new medical condition and treatment.

Question	Answer
Form Name	Standard Form 507
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	form om 501, google army form sf 507, sf 507 blank, online version of word

Standard Form 507 – Fill Out and Use This PDF

Standard Form 507 PDF Details

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