Medical Record-Supplemental Medical Data
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1MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General.
OTSG APPROVED
REPORT TITLE
(Date)
(YYYYMMDD)
(Continue on reverse)
PREPARED BY
DEPARTMENT/SERVICE/CLINIC
DATE (YYYYMMDD)
(Signature & Title)
PATIENT'S IDENTIFICATION (For typed or written entries give: Name
last,
first, middle; grade; date; hospital or medical facility)
HISTORY/PHYSICAL
FLOW CHART
OTHER
OTHER EXAMINATION
(Specify)
OR EVALUATION
DIAGNOSTIC STUDIES
TREATMENT
APD LC v1.01ES
DA FORM 4700, FEB 2003
EDITION OF MAY 78 IS OBSOLETE.
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