MEDICAL AND DENTAL PREPARATION FOR OVERSEAS MOVEMENT
For use of this form, see AR 600-8-11; the proponent agency is DCSPER
PRIVACY ACT STATEMENT
Title 10, USC, Sections 3010, 8012 and 5031, and Title 5, USC, Section 301.
Information is required on all soldiers being reassigned overseas to determine if they meet medical and
dental standards for such assignment.
(1) For personnel service support; and (2) Information is primarily obtained from review of records unless
assignment is to be an isolated area which requires evaluation and personal interview.
Disclosure of information is voluntary. If family members are required to complete medical and dental
evaluation and personal interview, but refuse to do so, they will not be permitted to accompany the soldier
to the oversea assignment.
NAME (Last, Middle, First)
GRADE OR RANK
PMOS OR AOC
PRESENT UNIT OF ASSIGNMENT
PROJECTED UNIT OF ASSIGNMENT (Include location/country)
PROJECTED DUTY MOS OR AOC (9 Position Code)
ANTICIPATED DATE OF LOSS
IS MEMBER BEING ASSIGNED TO AN
ISOLATED AREA AS DEFINED BY AR 40-501,
IF ANSWER TO ITEM 10 IS "YES" AND IF MEMBER IS REQUESTING FAMILY TRAVEL, ALL FAMILY MEMBERS WILL BE SCREENED BY THE LOCAL
MEDICAL TREATMENT FACILITY FOR SPECIAL MEDICAL AND FUNCTIONAL NEEDS. ENTER NAMES OF ALL ACCOMPANYING FAMILY MEMBERS, OTHERWISE
LIST ANY OTHER SPECIAL MEDICAL OR DENTAL INSTRUCTIONS CONTAINED IN THE ASSIGNMENT INSTRUCTIONS
NAME OF MPD/PSC REPRESENTATIVE
DA FORM 4036-R, MAY 90
DA FORM 4036-R, JAN 85 IS OBSOLETE