Fillable Dd Form 2807-1 - Defense Technical Information Center printable pdf download

OMB No. 0704-0413

REPORT OF MEDICAL HISTORY

OMB approval expires

(This information is for official and medically confidential use only and will not be released to unauthorized persons.)

Oct 31, 2017

The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering

and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,

including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive,

Alexandria, VA 22350-3100 (0704-0413). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a

collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM AS INDICATED ON PAGE 2.

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 136, DoD Instruction 6130.03, and E.O. 9397, as amended (SSN).

PRINCIPAL PURPOSE(S): The primary collection of this information is from individuals seeking to join the Armed Forces. The information collected on this form is used

to assist DoD physicians in making determinations as to acceptability of applicants for military service and verifies disqualifying medical condition(s) noted on the

prescreening form (DD 2807-2). An additional collection of information using this form occurs when a Medical Evaluation Board is convened to determine the medical

fitness of a current member and if separation is warranted. Completed forms are covered by recruiting, medical evaluation board, and official military personnel file SORNs

maintained by each of the Services.

ROUTINE USE(S): The Blanket Routine Uses found at apply to this collection.

DISCLOSURE: Voluntary. However, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application to enter the

Armed Forces. An applicant's SSN is used during the recruitment process to keep all records together and when requesting civilian medical records. For an Armed Forces

member, failure to provide the information may result in the individual being placed in a non-deployable status.The SSN of an Armed Forces member is to ensure the

collected information is filed in the proper individual's record.

WARNING: The information you have given constitutes an official statement. Federal law provides severe penalties (up to 5 years confinement or a

$10,000 fine or both), to anyone making a false statement. If you are selected for enlistment, commission, or entrance into a commissioning program

based on a false statement, you can be tried by military courts-martial or meet an administrative board for discharge and could receive a less than

honorable discharge that would affect your future.

1. LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX)

2. SOCIAL SECURITY NUMBER

3. TODAY'S DATE (YYYYMMDD)

4.a. HOME ADDRESS (Street, Apartment No., City, State, and ZIP Code)

5. EXAMINING LOCATION AND ADDRESS (Include ZIP Code)

b. HOME TELEPHONE (Include Area Code)

X ALL APPLICABLE BOXES:

7.a. POSITION (Title, Grade, Component)

c. PURPOSE OF EXAMINATION

6.a. SERVICE

b. COMPONENT

Coast

Army

Regular

Enlistment

Medical Board

Other

(Specify)

Guard

b. USUAL OCCUPATION

Navy

Reserve

Commission

Retirement

Marine Corps

National Guard

Retention

U.S. Service Academy

Air Force

Separation

ROTC Scholarship Program

8. CURRENT MEDICATIONS (Prescription and Over-the-counter)

9. ALLERGIES (Including insect bites/stings, foods, medicine or other substance)

Mark each item "YES" or "NO". Every item marked "YES" must be fully explained in Item 29 on Page 2.

HAVE YOU EVER HAD OR DO YOU NOW HAVE:

12. (Continued)

YES NO

10.a. Tuberculosis

f. Foot trouble (e.g., pain, corns, bunions, etc.)

g. Impaired use of arms, legs, hands, or feet

b. Lived with someone who had tuberculosis

c. Coughed up blood

h. Swollen or painful joint(s)

Asthma or any breathing problems related to exercise, weather,

i. Knee trouble

(e.g., locking, giving out, pain or ligament injury, etc.)

pollens, etc.

Any knee or foot surgery including arthroscopy or the use of a scope

e. Shortness of breath

to any bone or joint

Any need to use corrective devices such as prosthetic devices, knee

f. Bronchitis

brace(s), back support(s), lifts or orthotics, etc.

l. Bone, joint, or other deformity

g. Wheezing or problems with wheezing

m. Plate(s), screw(s), rod(s) or pin(s) in any bone

h. Been prescribed or used an inhaler

n. Broken bone(s) (cracked or fractured)

i. A chronic cough or cough at night

j. Sinusitis

13.a. Frequent indigestion or heartburn

k. Hay fever

b. Stomach, liver, intestinal trouble, or ulcer

c. Gall bladder trouble or gallstones

l. Chronic or frequent colds

11.a. Severe tooth or gum trouble

d. Jaundice or hepatitis (liver disease)

b. Thyroid trouble or goiter

e. Rupture/hernia

c. Eye disorder or trouble

f. Rectal disease, hemorrhoids or blood from the rectum

d. Ear, nose, or throat trouble

g. Skin diseases (e.g. acne, eczema, psoriasis, etc.)

e. Loss of vision in either eye

h. Frequent or painful urination

f. Worn contact lenses or glasses

i. High or low blood sugar

g. A hearing loss or wear a hearing aid

j. Kidney stone or blood in urine

h. Surgery to correct vision (RK, PRK, LASIK, etc.)

k. Sugar or protein in urine

Sexually transmitted disease (syphilis, gonorrhea, chlamydia, genital

12.a. Painful shoulder, elbow or wrist (e.g. pain, dislocation, etc.)

warts, herpes, etc.)

b. Arthritis, rheumatism, or bursitis

14.a. Adverse reaction to serum, food, insect stings or medicine

c. Recurrent back pain or any back problem

b. Recent unexplained gain or loss of weight

c. Currently in good health (If no, explain in Item 29 on Page 2.)

d. Numbness or tingling

e. Loss of finger or toe

d. Tumor, growth, cyst, or cancer

DD FORM 2807-1, MAR 2015

Page 1 of 3 Pages

DoD exception to SF 93 approved by ICMR, August 3, 2000.

PREVIOUS EDITION IS OBSOLETE.

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Dd Form 2807-1 - Defense Technical Information Center

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