Fillable Dmna Form 40-400 State Active Duty Pre/post Deployment Medical Screen printable pdf download

Dmna Form 40-400 State Active Duty Pre/post Deployment Medical Screen

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FOUO – WHEN FILLED IN

JOINT FORCE HEADQUARTERS – NY

STATE ACTIVE DUTY PRE/POST DEPLOYMENT MEDICAL SCREEN

PRE Deployment Worksheet

Name:

Last, Suffix

Date:

___/____/______mm/dd/yyyy

First, MI

DOB:

___/____/______mm/dd/yyyy

[ ] M

[ ] F

Unit:

Gender

Service Component

Operation Name:

[ ] NYANG

[ ] NYG

[ ] NYARNG

[ ] Naval Militia

Unit/ Team/ Task Force:

[ ] Other (explain)

JOA 1 (NYC)

JOA 1 (Long Island)

JOA 2

JOA 3

JOA 4

JOA 5

Location:

1. Would you say your health in general is: [ ] Excellent [ ] Very Good [ ] Good [ ] Fair [ ] Poor

Please explain:

2. Do you have any medical or dental conditions that affect your ability to perform the mission? [ ] Yes [ ] No

3. Are you currently on a Profile or “light duty” or are you undergoing a medical board?

[ ] Yes [ ] No

4. Are you pregnant? (Females ONLY)

[ ] Yes [ ] No

5. What medications are you taking? (prescribed, over the counter, vitamins, herbal)

[ ] None

Please list:

6. Do you NEED/REQUIRE any prescription that you do not have with you?

[ ] Yes [ ] No

(To include 30 days of medication, prescribed glasses, and/or other personal medical equipment)

7. During the past year, have you sought counseling or care for your mental health?

[ ] Yes [ ] No

8. Do you currently have any questions or concerns about your health?

[ ] Yes [ ] No

Please list:

9. Please explain any YES answer:

I certify that the responses on this form are true:

Signature

Administrative Review:

Medical Review:

Name :________________________ Date: ________

Title: _______________________ Initials: ________

This Document may contain information covered under the Privacy Act of 1974, 5USC SECTION 552 (a.) and/or the Health Insurance

Portability and Accountability Act of 1996 (HIPAA) (PL 104-191) and it’s various implementing regulations and must be protected in

accordance with those provisions. Healthcare information is personal and must be treated accordingly. If this correspondence contains

healthcare information it is being provided to you after the appropriate authorization. You, the recipient, are obligated to maintain it in a

safe, secure and confidential manner. Redisclosure without additional patient consent or as permitted by law is prohibited. Unauthorized

redisclosure or failure to maintain confidentiality subjects you to the application of appropriate sanction. This Information may be

provided to appropriate Government agencies when relevant to civil, criminal, or regulatory investigations or prosecutions.

DMNA Form 40-400, 22 October 2014, Replaces edition of 10 SEP 13 which is obsolete and will no longer be used.

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Dmna Form 40-400 State Active Duty Pre/post Deployment Medical Screen

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