Dd Form 2697 - Report Of Medical Assessment
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1
2REPORT CONTROL SYMBOL
REPORT OF MEDICAL ASSESSMENT
DD-HA(AR)1939
PRIVACY ACT STATEMENT
AUTHORITY: PL 103-160, EO 9397.
PRINCIPAL PURPOSE: To be used by the Medical Services to provide a comprehensive medical assessment for active and reserve component
service members separating or retiring from active duty.
ROUTINE USES: A copy of this form will be released to the Department of Veterans Affairs.
DISCLOSURE: Voluntary; however, failure to disclose the requested personal information may result in delay in processing any disability claim.
SECTION I - TO BE COMPLETED BY SERVICE MEMBER. Any service member who requests a physical examination may have one.
1.
NAME
(Last, First, Middle)
2.
SOCIAL
SECURITY NUMBER
3. RANK
4.
COMPONENT
5.
UNIT
OF ASSIGNMENT
6a. HOME STREET ADDRESS (Or RFD, including
b. CITY
c. STATE
d. ZIP CODE
7.
HOME
TELEPHONE NUMBER
apartment number)
(Include area code)
8.
DATE OF LAST
PHYSICAL EXAMINATION BY THE MILITARY
9.
DATE ENTERED ON
CURRENT ACTIVE DUTY (YYMMDD)
(YYMMDD)
10. COMPARED TO MY LAST MEDICAL ASSESSMENT/PHYSICAL EXAMINATION, MY OVERALL HEALTH IS (X one. If "Worse," explain.)
THE SAME
BETTER
WORSE
11.
SINCE YOUR
LAST MEDICAL ASSESSMENT/PHYSICAL EXAMINATION, HAVE YOU HAD ANY ILLNESSES OR INJURIES THAT CAUSED
YOU TO MISS DUTY FOR LONGER THAN 3 DAYS? (X one. If "Yes," explain.)
NO
YES
12.
SINCE YOUR LAST
MEDICAL ASSESSMENT/PHYSICAL EXAMINATION, HAVE YOU BEEN SEEN BY OR BEEN TREATED BY A HEALTH
CARE PROVIDER, ADMITTED TO A HOSPITAL, OR HAD SURGERY? (X one. If "Yes," explain.)
NO
YES
13. HAVE YOU SUFFERED FROM ANY INJURY OR ILLNESS WHILE ON ACTIVE DUTY FOR WHICH YOU DID NOT SEEK MEDICAL CARE?
(X one. If "Yes," explain.)
NO
YES
14.
ARE YOU
NOW TAKING ANY MEDICATIONS? (X one. If "Yes," list medications.)
NO
YES
15. DO YOU HAVE ANY CONDITIONS WHICH CURRENTLY LIMIT YOUR ABILITY TO WORK IN YOUR PRIMARY MILITARY SPECIALTY OR
REQUIRE GEOGRAPHIC OR ASSIGNMENT LIMITATIONS? (X one. If "Yes," explain.)
NO
YES
16.
DO
YOU HAVE ANY DENTAL PROBLEMS? (X one. If "Yes," explain.)
NO
YES
17.
DO
YOU HAVE ANY OTHER QUESTIONS OR CONCERN ABOUT YOUR HEALTH? (X one. If "Yes," explain.)
NO
YES
18.
AT THE PRESENT
TIME, DO YOU INTEND TO SEEK DEPARTMENT OF VETERANS AFFAIRS (VA) DISABILITY?
(X one. If "Yes," list conditions for which you will ask for VA Disability.)
NO
YES
UNCERTAIN
19.
CERTIFICATION.
I certify that the information provided above is true and complete to the best of my knowledge.
a.
SIGNATURE OF SERVICE MEMBER
b. DATE SIGNED
DD FORM 2697, FEB 95 (EG)
Designed using Perform Pro, WHS/DIOR, Feb 95
Adobe Professional 7.0
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