Dd Form 2808 - Report Of Medical Examination - 2005 Page 3

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LAST NAME - FIRST NAME - MIDDLE NAME (SUFFIX)
SOCIAL SECURITY NUMBER
74.a. EXAMINEE/APPLICANT (check one)
75. I have been advised of my disqualifying condition.
a. SIGNATURE OF EXAMINEE
b. DATE
IS QUALIFIED FOR SERVICE
(YYYYMMDD)
IS NOT QUALIFIED FOR SERVICE
b. PHYSICAL PROFILE
P
U
L
H
E
S
X
PROFILER INITIALS
DATE (YYYYMMDD)
76. SIGNIFICANT OR DISQUALIFYING DEFECTS
WAIVER RECEIVED
DIS-
ITEM
ICD
PROFILE
RBJ DATE
EXAMINER
QUALI-
MEDICAL CONDITION/DIAGNOSIS
QUALI-
FIED
NO.
CODE
SERIAL
INITIALS
(YYYYMMDD)
FIED
SERVICE
DATE
(YYYYMMDD)
77. SUMMARY OF DEFECTS AND DIAGNOSES (List diagnoses with item numbers) (Use additional sheets if necessary.)
78. RECOMMENDATIONS - FURTHER SPECIALIST EXAMINATIONS INDICATED (Specify) (Use additional sheets if necessary.)
79. MEPS WORKLOAD (For MEPS use only)
WKID
ST
DATE
INITIAL
WKID
ST
DATE
INITIAL
(YYYYMMDD)
(YYYYMMDD)
80. MEDICAL INSPECTION DATE
HT
WT
%BF
MAX WT
HCG
QUAL
DISQ
PHYSICIAN'S SIGNATURE
81.a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER
b. SIGNATURE
82.a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER
b. SIGNATURE
83.a. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN (Indicate which)
b. SIGNATURE
84.a. TYPED OR PRINTED NAME OF REVIEWING OFFICER/APPROVING AUTHORITY
b. SIGNATURE
85. This examination has been administratively reviewed for completeness and accuracy.
a. SIGNATURE
b. GRADE
c. DATE (YYYYMMDD)
87. NUMBER OF
86. WAIVER GRANTED (If yes, date and by whom)
ATTACHED SHEETS
YES
NO
DD FORM 2808, OCT 2005
Page 3 of 3 Pages

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