Present Health Questionnaire - Dodmerb printable pdf download

DoD Medical Examination Review Board

8034 Edgerton Drive, Suite 132

USAF Academy, Colorado 80840-2200

PRESENT HEALTH QUESTIONNAIRE

NAME: __________________________SOCIAL SECURITY NUMBER: ______-____-______

Please complete the questions below (referring to the timeframe from your last DoDMERB exam to

present day) and return this form to DoDMERB at the above address: If more space is needed,

please use back of form and identify each issue by question number.

_____________________________________________________________________________________

PRIVACY ACT STATEMENT

AUTHORITY: Title 10, USC 133, 3012, 5031, 8013, and Executive Order 9397

PRINCIPAL PURPOSE: To determine medical acceptability or update a medical file as part of the application process to a United States

Service Academy, Reserve Officer Training Corp (ROTC) Scholarship Program, or the Uniformed Services University of the Health Sciences

(USUHS).

ROUTINE USES: This information may be disclosed to the Coast Guard Academy and Merchant Marine Academy for applicants to their

Academies.

DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection process and hamper your candidacy.

Use of the Social Security Number (SSN) is used for positive identification of records.

_____________________________________________________________________________________________________________________

1) Please make a statement of your present health: ____________________________________________

____________________________________________________________________________________

2) Have you received any medical, psychiatric or dental care since your last DoDMERB exam? YES NO

If yes, provide specific details: _________________________________________________________

____________________________________________________________________________________

3) Since your last DoDMERB exam, please list name(s) of medication(s) and reason for taking them (If

you have not taken any medications, state “NONE”): __________________________________________

_____________________________________________________________________________________

4) Certification: By signing below, I hereby certify that I have not received (other than mentioned above)

any medical or dental care/treatment since the date of my last DoDMERB examination.

_________________________________________

_____________________

Applicant’s Signature

Date

Present Health Questionnaire

Present Health Questionnaire - Dodmerb