Dmna Form 40-400 State Active Duty Pre/post Deployment Medical Screen Page 2
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1
2FOUO – WHEN FILLED IN
JOINT FORCE HEADQUARTERS – NY
STATE ACTIVE DUTY PRE/POST DEPLOYMENT MEDICAL SCREEN
POST 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)
Location:
JOA 1 (NYC)
JOA 1 (Long Island)
JOA 2
JOA 3
JOA 4
JOA 5
1. Would you say your health in general is: [ ] Excellent [ ] Very Good [ ] Good [ ] Fair [ ] Poor
Please explain:
2. Do you have any outstanding medical or dental conditions?
[ ] Yes [ ] No
3. Have you sought/received medical treatment during this deployment?
[ ] Yes [ ] No
4. Do you have an illness and/or injury as a result of your deployment?
[ ] Yes [ ] No
5. Do you have any Line of Duty (LOD) reports related to this deployment?
[ ] Yes [ ] No
6. Do you desire any counseling, care or support for your mental health?
[ ] Yes [ ] No
7. Do you currently have any questions or concerns about your health?
[ ] Yes [ ] No
Please list:
8. Please explain any YES answer:
I certify that the responses on this form are true:
X
Signature
Administrative Review:
Medical Review:
Name :________________________ Date: ________
Name :________________________ Date: ________
Title: _______________________ Initials: ________
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 its 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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