Sere Physical Exam Checklist (Dd Form 2808, Dd Form 2807-1)
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1SERE PHYSICAL EXAM CHECKLIST
as of 20150730
Chapter 2, Chapter 5, para 5-3 (a-v), Chapter 8, para 8-12 (a, b, g), 8-13 (a - c), 8-14 (a7), 8-24 (a1 & 2)
NAME_______________________ SSN____________ CLASS / YG_______ STN________
Block #
DD Form 2808 pages 1-3, Report of Medical Examination
1 - 15b
________
Examinee information / General Information, all legible and current
15c
________
Purpose of exam (SERE/ABN)
16
________
Name of examining location -- Hospital / Clinic / TMC
17 - 42
________
Clinical Evaluation (Any Abnormalities must be explained in notes)
35
________
Feet (Should not be symptomatic, pes planus)
45
________
Urinalysis (Must be < than 2.00 specific gravity)
45a
________
Albumin (Negative or trace only)
45b
________
Sugar (Negative only)
46
________
HCG (Females only, Negative only), 52. a, b, c
47
________
HCT / HGB (Male: 13.5 or higher; Female: 12.0 or higher) AR 40-501 para 2-4(a)
48
________
Blood Type
49
________
HIV (Negative only)
53 - 55
________
Height / Weight -- (If over max weight include tape test)
57
________
Pulse (Not over 99) AR 40-501 para 2-18g
58a - c
________
Blood Pressure (MAX’s 140 / 90), If high, will need a 5 day BP Check
59
________
Vivid Red / Green Pass (Required of SM when he fails color test in item # 66
Distant Vision (corrected to at least: 20/40 in one eye and 20/100 in the other eye, or 20/30 in one eye
61 & 63
________
and 20/200 in the other eye, or 20/20 in one eye and 20/800 in the other eye)
62
________
Refraction- PRK worksheet (required if had eye surgery; in between + or - 8 diopters max)
66
________
Color Vision (If SM fails PIP or falant test, must be able to pass Vivid Red / Green test, item # 59)
71a
________
Hearing - 500 - 2000hz - Average less than 30db per ear, not one range above 35db
3000hz - not more than 45db, 4000hz - not more than 55db
72b
________
Valsalva (Should be SAT OR +)
73
________
In the Notes Section: No Fear Statement, Rectal Exam, Hemmocult / Occult Blood
CHOL, LDL, HDL, TRI, Sickle Cell, RPR
EKG must be signed by the physician
74a
________
Qualified / Not Qualified (Must state SERE/ABN )
74b
________
Physical Profile and Category (MIN 111121) (111221)
81a, 82a, 84a ________
Doctor (MD) and Physician Assistant (PA) signatures
DD Form 2807-1 pages 1-3, Report of Medical History
Block #
1 - 6b
________
Examinee information, legible and current
6c
________
Purpose of exam (SERE/ABN)
8
________
Current Medications
9
________
Current Allergies
10 - 28
________
Completely filled out, All Yes answers must be explained in Item 29, page 2, 2807-1
29
________
All Yes answers will be fully explained by examinee
30
________
All Yes answers by the examinee will be fully explained by PA or DR
30b - c
________
Doctor or Physician Assistant signature and date
All Lab results should be annotated on DD 2808 – Retain copy of lab printout in Residual file but do not scan in with physical
Chest X-ray – Should be annotated on DD 2808 as Normal - Retain copy of lab printout in Residual file but do not scan in with physical
EKG / ECG – Should be annotated on DD 2808 as Normal - Retain copy of lab printout in Residual file and scanned in with physical
Physical QC’d BY: _________________________________
Physical QC’d BY: _________________________________
RECRUITER
CENTER COMMANDER
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