Standard Form 88 PDF Details

When it comes to comprehensive health assessments, the Standard Form 88 (SF-88), known as the "Report of Medical Examination," is a critical document commonly used in various federal employment and military settings. This detailed form captures a wide array of personal and health-related information, ranging from basic identifiers like name and date of birth to intricate details regarding an individual's medical examination results. The form meticulously outlines components such as emergency contact information, identification numbers, and demographic specifics, including race and place of birth. Additionally, the SF-88 delves into the clinical evaluation of numerous health aspects, such as vision and hearing acuity, the condition of the heart, lungs, and vascular system, psychological and psychiatric assessments, and even dental health. Moreover, it incorporates results from various tests including urinalysis, chest X-rays, blood typing, and more. Such thorough medical documentation serves multiple purposes, from assessing fitness for duty to identifying potential health problems, thereby playing a crucial role in managing the well-being of government employees and military personnel.

QuestionAnswer
Form NameStandard Form 88
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesstandard form 88 army fillable, sf 88 and sf 93, sf88, sf88 form

Form Preview Example

MEDICAL RECORD

REPORT OF MEDICAL EXAMINATION

DATE OF EXAM

1. LAST NAME - FIRST NAME - MIDDLE NAME

2. IDENTIFICATION NO.

3. GRADE AND COMPONENT OR POSITION

 

 

 

4. HOME ADDRESS (Number, street or RFD, city or town, state and ZIP Code)

5. EMERGENCY CONTACT (Name and address of contact)

6. DATE OF BIRTH

7. AGE

 

8. SEX

 

 

 

9. RELATIONSHIP OF CONTACT

 

 

 

 

 

 

 

 

 

 

 

 

FEMALE

 

MALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. PLACE OF BIRTH

 

 

11. RACE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WHITE

 

BLACK

 

 

AMERICAN INDIAN/

 

 

HISPANIC

 

HISPANIC

 

 

ASIAN/PACIFIC

 

 

 

 

 

 

 

ALASKA NATIVE

 

 

WHITE

 

BLACK

 

 

ISLANDER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12a. AGENCY

 

 

12b. ORGANIZATION UNIT

 

 

 

 

 

13. TOTAL YEARS GOVERNMENT SERVICE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. MILITARY

 

 

b. CIVILIAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. NAME OF EXAMINING FACILITY OR EXAMINER, AND ADDRESS

 

 

 

15. RATING OR SPECIALTY OF EXAMINER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16. PURPOSE OF EXAMINATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17. CLINICAL EVALUATION

NOR-

(Check each item in appropriate column, enter "NE" if not evaluated.)

ABNOR-

NOR-

(Check each item in appropriate column, enter "NE" if not evaluated.)

ABNOR-

MAL

MAL

MAL

MAL

 

 

 

 

A. HEAD, FACE, NECK AND SCALP

 

 

O. PROSTATE (Over 40 or clinically indicated)

 

 

 

 

 

 

 

 

 

B. EARS - GENERAL (INTERNAL CANALS)

 

 

P. TESTICULAR

 

 

 

 

 

 

 

 

 

(Auditory acuity under items 39 and 40)

 

 

Q. ANUS AND RECTUM (Hemorrhoids, Fistulae) (Hemocult Results)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. DRUMS (Perforation)

 

 

R. ENDOCRINE SYSTEM

 

 

 

 

 

 

 

 

 

 

D. NOSE

 

 

S. G-U SYSTEM

 

 

 

 

 

 

 

 

 

 

E. SINUSES

 

 

T. UPPER EXTREMITIES

(Strength, range of motion)

 

 

 

 

 

 

 

 

 

F. MOUTH AND THROAT

 

 

U. FEET

 

 

 

 

 

 

 

 

 

G. EYES GENERAL (Visual acuity and refraction under items 28, 29, and 30)

 

 

V. LOWER EXTREMITIES (Except feet) (Strength, range of motion)

 

 

 

 

 

 

 

 

H. OPHTHALMOSCOPIC

 

 

W. SPINE, OTHER MUSCULOSKELETAL

 

 

 

 

 

 

 

 

I. PUPILS (Equality and reaction)

 

 

X. IDENTIFYING BODY MARKS, SCARS, TATTOOS

 

 

 

 

 

 

 

 

 

J. OCULAR MOTILITY (Associated parallel movements nystagmus)

 

 

Y. SKIN, LYMPHATICS

 

 

 

 

 

 

 

 

 

K. LUNGS AND CHEST

 

 

Z. NEUROLOGIC (Equilibrium tests under item 42)

 

 

 

 

 

 

 

 

L. HEART (Thrust, size, rhythm, sounds)

 

 

AA. PSYCHIATRIC (Specify any personality deviation)

 

 

 

 

 

 

 

 

 

M. VASCULAR SYSTEM (Varicosities, etc.)

 

 

BB. BREASTS

 

 

 

 

 

 

 

 

 

N. ABDOMEN AND VISCERA (Include hernia)

 

 

CC. PELVIC (Females only)

 

 

 

 

 

 

 

 

NOTES: (Describe every abnormality in detail. Enter pertinent item number before each comment. Continue in item 42 and use additional sheets if necessary)

18.DENTAL (Place appropriate symbols, shown in examples, above or below number of upper and lower teeth.)

 

 

 

0

 

 

Restorable

 

/

 

 

Non-

 

 

x

 

 

Missing

 

x

x

x

 

Replaced

 

(

x

)

Fixed

 

 

1

2

3

 

1

2

3

 

restorable

 

1

2

3

 

 

1

2

3

 

by

 

1

2

3

Partial

 

32 31

30

Teeth

32

31

30

32

31

30

Teeth

32

31

30

32

31

30

 

Teeth

Dentures

Dentures

 

 

 

0

 

 

 

 

/

 

 

 

 

 

x

 

 

 

 

x

x

x

 

(

x

)

 

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

G

1

 

2

3

4

5

 

6

7

8

 

 

9

10

11

 

12

 

13

14

15

16

32

 

31

30

29

28

 

27

26

25

 

 

24

23

22

 

21

 

20

19

18

17

F

H

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

T

T

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REMARKS AND ADDITIONAL DENTAL DEFECTS AND DISEASES

19. TEST RESULTS (Copies of results are preferred as attachments)

A. URINALYSIS: (1) SPECIFIC GRAVITY

 

 

 

 

B. CHEST X-RAY OR PPD (Place, date, film number and result)

 

 

 

 

 

 

(2) URINE ALBUMIN

(4) MICROSCOPIC

 

 

 

 

 

 

 

 

 

(3) URINE SUGAR

 

 

 

 

 

 

 

 

 

C. SYPHILIS SEROLOGY (Specify test used and

D. EKG

 

E. BLOOD TYPE AND RH

F. OTHER TESTS

results)

 

 

FACTOR

 

 

 

 

 

 

 

NSN 7540-00-634-4038

STANDARD FORM 88 (Rev.10-94)

 

 

Prescribed by GSA/ICMR FIRMR (41CFR) 201-9.202-1

USAPPC V2.00

NAME

IDENTIFICATION NUMBER

NO. OF SHEETS ATTACHED

MEASUREMENTS AND OTHER FINDINGS

20. HEIGHT

21. WEIGHT

22. COLOR HAIR

23. COLOR EYES

24. BUILD:

SLENDER

MEDIUM

HEAVY

OBESE

25. TEMPERATURE

 

 

26. BLOOD PRESSURE (Arm at heart level)

 

 

 

 

 

27. PULSE (Arm at heart level)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A.

SYS.

 

B.

SYS.

C.

SYS.

 

A. SITTING

 

B. RECUMBENT

C. STANDING

D. AFTER EXERCISE

E. 2 MINS. AFTER

 

 

 

 

 

 

 

RECUM-

 

 

 

 

 

 

 

(3 MINS)

 

 

SITTING

DIAS.

 

DIAS.

STANDING

DIAS.

 

 

 

 

 

 

 

 

BENT

 

 

 

 

 

 

 

 

 

 

 

 

(5 mins.)

 

 

 

 

 

 

 

 

 

28. DISTANT VISION

 

 

 

29. REFRACTION

 

 

 

30. NEAR VISION

 

 

 

 

 

 

 

 

 

 

 

RIGHT 20/

 

CORR. TO 20/

 

BY

 

S.

CX

 

CORR. TO

BY

 

 

 

 

 

 

 

 

 

 

 

LEFT 20/

 

CORR. TO 20/

 

BY

 

S.

CX

 

CORR. TO

BY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

31.HETEROPHORIA (Specify distance)

ESO

EXO

R.H.

 

 

L.H.

 

 

PRISM DIV.

 

 

PRISM CONV.

PC

PD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CT

 

 

 

32. ACCOMMODATION

 

 

33. COLOR VISION (Test used and result)

 

 

 

 

34. DEPTH PERCEPTION

 

UNCORRECTED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Test used and score)

 

 

 

RIGHT

LEFT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CORRECTED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

35. FIELD OF VISION

 

 

36. NIGHT VISION (Test used and score)

 

 

 

 

37. RED LENS TEST

 

38. INTRAOCULAR TENSION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RIGHT

LEFT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RIGHT

LEFT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

39. HEARING

 

 

 

 

 

40. AUDIOMETER

 

 

 

 

41. PSYCHOLOGICAL AND PSYCHOMOTOR (Tests used and scores)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RIGHT WV

/15 SV

/15

 

 

250

500

1000

2000

3000

4000

6000

8000

 

 

 

 

 

 

256

512

1024

2048

2896

4096

6144

8192

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RIGHT

 

 

 

 

 

 

 

 

 

 

 

 

 

LEFT WV

/15 SV

/15

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEFT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

42. NOTES (Continued)

AND SIGNIFICANT OR INTERVAL HISTORY

 

 

 

 

 

 

 

 

 

 

 

 

(Use additional sheets if necessary)

43.SUMMARY OF DEFECTS AND DIAGNOSES (List diagnoses with item numbers)

44.

RECOMMENDATIONS - FURTHER SPECIALIST EXAMINATIONS INDICATED (Specify)

 

 

 

 

45A. PHYSICAL PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P

 

U

L

 

H

E

 

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

46.

EXAMINEE (Check)

 

 

 

 

 

 

 

 

 

 

A.

 

IS QUALIFIED FOR

 

 

 

 

45B. PHYSICAL CATEGORY

 

 

 

 

 

 

 

B.

 

IS NOT QUALIFIED FOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

47.

IF NOT QUALIFIED, LIST DISQUALIFYING DEFECTS BY ITEM NUMBER

 

A

 

B

 

 

C

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

48. TYPED OR PRINTED NAME OF PHYSICIAN

SIGNATURE

49. TYPED OR PRINTED NAME OF PHYSICIAN

SIGNATURE

50. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN (Indicate which)

SIGNATURE

51. TYPED OR PRINTED NAME OF REVIEWING OFFICER OR APPROVING AUTHORITY

SIGNATURE

STANDARD FORM 88 (Rev. 10-94) BACK

USAPPC V2.00