Da Form 7246 - Exceptional Family Member Program (Efmp) Screening Questionnare Page 2
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1
2YES
NO
4. Are any family members, excluding service member, taking any prescribed medication other than birth control pills on a
regular basis?
NAME
PRESCRIBED MEDICATION
5. In the past five (5) years, have any members of your family, excluding service member, been treated for, or had any problems related to any
of the following? (You will have an opportunity to discuss all "YES" answers with a screener.)
a.
Problems with sight (other than corrected by
YES
NO
YES
NO
g.
Asthma, allergies or other respiratory problems
glasses)
b.
Problems with hearing
h.
Cerebral Palsy
c.
Heart condition
i.
Delayed Speech
d.
Seizure disorder
j.
Sickle Cell Trait/Disease
e.
Loss of mobility (requiring use of a wheelchair/
k.
Cancer
walker or aid in mobility)
l.
High blood pressure
f.
Diabetes
m.
Other, if yes, explain
MENTAL HEALTH:
6. In the past five (5) years, have any members of your family, excluding service member, been treated for, or had any problems related to any
of the following? (You will have an opportunity to discuss all "YES" answers with a screener.)
a.
Referral to, diagnosed by, or therapy with a
YES
NO
YES
NO
Psychiatrist, Psychologist, or Social Worker
d.
Alcohol and drug use or abuse
in reference to a mental health problem
e.
Emotional problems
b.
Depression
f.
Behavioral problems/acting out behavior
g.
Received therapy (marital, family, individual or
c.
Suicidal thoughts/ideas, gestures, attempts
group counseling)
YES
NO
7. Have any members of your family, excluding service member, been in any of the following? Inpatient Psychiatric Facility,
Residential Treatment Center, Group Homes, Day Treatment Centers, Drug and Alcohol Treatment Rehabilitation Center. If
Yes, please explain:
EDUCATION
8. Do any of your children now have, or have they ever had, any of the following?
a.
YES
NO
YES
NO
Slow development (infants and preschoolers)
Counseling services for school-related problems
d.
b.
Learning problems (school)
c.
Special services (i.e., OT, PT, Speech, etc.)
e.
Mental retardation
for special education
YES
NO
9. Are any of your children receiving Special Education help in school (not in regular class placement and on an Individual
Education Plan (IEP)) ? If yes, who?
According to AR 608-75, Exceptional Family Member Program, soldiers will provide accurate information as required when requested to do so
by Army officials. Knowingly providing false information in this regard may be the basis for disciplinary or administrative action. For soldiers,
refusal to provide information may preclude successful processing of an application for family travel or command sponsorship.
Commanders will take appropriate action against soldiers who knowingly provide false information, or who knowingly fail or refuse to enroll
family members that meet the criteria for enrollment. (A false official statement is a violation of Article 107, Uniform Code of Military Justice
(UCMJ).) These actions will include, at a minimum, a general officer letter of reprimand.
All the above information is true and correct to the best of my knowledge. I understand that it is my responsibility to provide any information
about changes in medical or educational status for all members of my family, after the date indicated below, and prior to PCS move.
PRINTED NAME OF MILITARY SPONSOR OR
SIGNATURE OF MILITARY SPONSOR OR SPOUSE
DATE (YYYYMMDD)
COMPLETING THIS FORM
SPOUSE COMPLETING THIS FORM
SIGNATURE OF PHYSICIAN OR MEDICAL
PRINTED NAME OF PHYSICIAN OR MEDICAL
DATE (YYYYMMDD)
PRACTITIONER IF UNDER THE SUPERVISION OF A
PRACTITIONER IF UNDER THE SUPERVISION OF A
PHYSICIAN
PHYSICIAN
APD PE v1.00ES
PAGE 2, DA FORM 7246, JUN 2009
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