Da Form 4036-R Medical And Dental Preparation For Overseas Movement Page 2
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1
2Complete the medical and dental status portions below, return the original and one copy to the MDP/PSC within 21 calendar
days of the date shown in item 13E, and forward one copy to the address in item 6.
MEDICAL STATUS
14A. PHYSICAL PROFILE SERIAL CODE
B.
PHYSICAL CATEGORY CODE
C.
MEDICAL RECORDS REVEAL THE FOLLOWING ASSIGNMENT
(PULHES)
LIMITATIONS
YES
NO
N/A
ITEM
B.
IF CONDITION IS TEMPORARY, EXPECTED DATE
15A.
Does the member meet the medical fitness
MEMBER WILL BE ELIGIBLE FOR ASSIGNMENT
standards outlined in AR 40-501?
(If "no" explain
briefly.)
B.
DATE, TIME AND LOCATION OF APPOINTMENT
16A.
Has member completed HIV screening?
B.
IF "YES", EXPECTED DATE OF DELIVERY
17A.
Is the member pregnant?
B.
IF "YES", INDICATE DATE, TIME, AND LOCATION OF
18A.
All active duty and reserve personnel of PCS
APPOINTMENT
assignment to Korea will be vaccinated with hepatitis
B vaccine. Does the member require immunization?
B.
IF "YES", INDICATE DATE, TIME, AND LOCATION OF
APPOINTMENT
19A.
Does the member require remedial medical care?
B.
IF "YES", INDICATE DATE THE MEMBER ENTERED
20A.
Is the member currently undergoing alcohol or
THE REHABILITATION PROGRAM
drug abuse rehabilitation?
B.
IF "YES", THE MEMBER (and family members, if
21A.
If item 10 is checked "yes", can the member be
applicable) MUST BE SCHEDULED FOR A FOLLOW-UP
assigned to an area where medical facilities are limited or
EVALUATION OF MEDICAL STATUS WITHIN 30 CALENDAR
nonexistent?
DAYS OF THE ANTICIPATED DATE OF LOSS (Item 9).
INDICATE DATE, TIME AND LOCATION OF APPOINTMENT(S)
22. Medical Records Indicate the Member Requires the Following (Check those appropriate)
REQUIRES
HAS
MISSING
ITEM
DATE, TIME AND LOCATION OF APPOINTMENT, IF NEEDED
A.
Two pairs of spectacles
B.
Protective mask spectacle
insert
C.
Two hearing aids
D.
Medical warning tag
23A.
NAME OF MEDICAL OFFICER
B.
TITLE
C.
SIGNATURE
D.
GRADE
E.
DATE
DENTAL STATUS (Complete only if Item 10 is checked "Yes" or if required by item 12.)
B.
IF "NO", BRIEFLY EXPLAIN. IF CONDITION IS TEMPORARY, EXPECTED
YES
NO
DATE THE MEMBER WILL BE ELIGIBLE FOR ASSIGNMENT
24A.
Is the member dentally qualified?
B.
IF "YES", INDICATE DATE, TIME, AND LOCATION OF APPOINTMENT
25A.
Does the member require remedial dental
care?
B.
IF "YES", THE MEMBER (and family members, if applicable) MUST BE
21A.
If item 10 is checked "yes", can the
SCHEDULED FOR A FOLLOW-UP EVALUATION OF MEDICAL STATUS WITHIN
member be assigned to an area where dental
30 CALENDAR DAYS OF THE ANTICIPATED DATE OF LOSS (Item 9).
facilities are limited or nonexistent?
INDICATE DATE, TIME, AND LOCATION OF APPOINTMENT(S)
27A.
NAME OF DENTAL OFFICER
B.
TITLE
C.
SIGNATURE
D.
GRADE
E.
DATE
REVERSE, DA FORM 4036-R, MAY 90
USAPPC V1.00
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