Dd Form 2492 Dod Medical Examination Review Board (Dodmerb) Report Of Medical History printable pdf download

FORM II

DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)

OMB No. 0704-0396

REPORT OF MEDICAL HISTORY

OMB approval expires

Nov 30, 2009

(This information is for official and medically confidential use only and will not be released to unauthorized persons.)

The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering

and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,

including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon, Washington, DC 20301-1155

(0704-0396). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not

display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO DODMERB/DR, 8034

EDGERTON DRIVE, SUITE 132, USAF ACADEMY CO 80840-2200.

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 Corps (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 applications 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.

2. STUDENT ID NUMBER

1. NAME (Last, First, Middle Initial)

3. TELEPHONE NO. (Include area code)

4. PURPOSE OF EXAMINATION

5. EXAMINATION FACILITY OR EXAMINER AND ADDRESS (Include ZIP Code)

6. DATE OF EXAMINATION

(YYYYMMDD)

Mark each item "Yes" or "No". EVERY QUESTION MUST BE ANSWERED, OR PROCESSING DELAYS WILL OCCUR.

Every "Yes" must be

explained in Block 83, REMARKS, on the back of the form. Mark and explain each item to the best of your ability. Be perfectly honest! Your medical records may be

requested to clarify your medical history.

7. HAVE YOU EVER OR DO

DO YOU

YES

9a. If you wear contact lenses, how many days have they

YOU NOW USE ANY OF

been removed prior to this examination?

Marijuana

THE FOLLOWING:

8. Wear glasses

YES

9. Wear contact lenses or

Alcohol (Amount,

Amphetamines

Less than 3

3 - 20

21 or over

frequency, treatment,

corneal eye retainers

if any)

Barbiturates

Type lens:

Hard

Soft

(If Yes, complete 9a.)

Cocaine

Chemical Inhalants

10. HAVE YOU EVER HAD YOUR VISION IMPROVED BY METHODS OTHER THAN STATED IN

QUESTIONS 8 OR 9?

Narcotic Drugs

Hallucinogens

YES

HAVE YOU EVER HAD OR DO YOU NOW HAVE:

YES

11. Eye trouble (exclude glasses, contact lenses)

40. Gallbladder trouble or gallstones

66. Sleepwalking episodes after age 12

12. Have fluctuating vision or double vision

41. Hepatitis (yellow jaundice)

67. Easily fatigued

13. Have any allergies

42. Hemorrhoids or rectal disease

68. Motion sickness (car, train, sea, or air)

14. Take any medications regularly

43. Black or bloody stools

69. X-ray or other radiation therapy

15. Stutter or stammer

44. Frequent or painful urination

70. Sensitivity to chemicals, dust, sunlight, etc.

16. Frequent, severe, or migraine headaches

45. Bed wetting after age 12

71. Learning disabilities or speech problems

HAVE YOU EVER

17. Fainting or dizzy spells

46. Blood, protein, or sugar in urine

YES

18. Periods of unconsciousness

47. History of diabetes

72. Been refused employment or been unable to

hold a job or stay in school because of:

19. Head injury or skull fracture

48. Kidney stone

20. Epilepsy, seizures or convulsions

49. Hernia or rupture

a. Inability to perform certain movements?

21. Loss of memory (amnesia)

50. Any bone or joint problem, injuries, surgery

b. Inability to assume certain positions?

or medical treatment

22. Depression, anxiety, excessive worry, or

c. Other medical reasons?

nervousness

73. Been rejected for or discharged from military

51. Steel pins, plates, or staples in any bones

service because of physical, mental or other

23. Any mental condition or illness

52. Wear a bone or joint brace or support

reasons?

74. Been denied or rated up for life insurance?

24. Frequent trouble sleeping

53. Back pain or trouble

25. Hearing loss

54. Paralysis or weakness

75. Received or applied for pension or

compensation for existing disability?

26. Ear, nose, or throat trouble

55. Foot trouble/use orthotics

27. Sinusitis or sinus trouble

56. Rheumatic fever

76. Had or been advised to have, any surgical

operations?

28. Hay fever or allergic rhinitis

57. Tuberculosis or positive TB test

77. Consulted, or been treated by clinics,

29. Tooth/gum trouble, or current orthodontics

58. Sexually transmitted disease (syphilis,

hospitals, physicians, healers, or other

gonorrhea, herpes)

30. Thyroid trouble

practitioners for other than minor illnesses?

31. Chronic cough or lung disease

59. Skin conditions such as acne, psoriasis,

78. Had any injury or illness other than those

already noted?

hand or foot rashes, eczema, or dry skin

32. Asthma or wheezing

YES

FEMALES ONLY

33. Unusual shortness of breath

(Complete Items 79 - 82)

60. Adverse reaction to vaccines, drugs,

medicines, foods, insect bites or stings

34. Pain or pressure in chest

79. Been treated for a female disorder, painful

periods, or cramps

35. Palpitation or pounding heart

61. Eating disorder

36. Heart trouble or heart murmur

62. Recent gain or loss of weight

80. Had a change in menstrual pattern

37. High blood pressure

63. Excessive bleeding or easy bruising

81. Are you now pregnant?

82. Date of last menstrual period (YYYYMMDD)

38. Coughed up or vomited blood

64. Tumor, growth, cyst, or cancer

39. Stomach, liver, or intestinal trouble

65. Considered or attempted suicide

DD FORM 2492, MAR 2008

PREVIOUS EDITION IS OBSOLETE.

DoD Exception to SF93 approved by GSA/IRMS (8-91)

Adobe Professional 7.0

Dd Form 2492 Dod Medical Examination Review Board (Dodmerb) Report Of Medical History

Related Articles

Related forms

Related Categories