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
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
9a. If you wear contact lenses, how many days have they
YOU NOW USE ANY OF
been removed prior to this examination?
8. Wear glasses
9. Wear contact lenses or
Less than 3
3 - 20
21 or over
corneal eye retainers
(If Yes, complete 9a.)
10. HAVE YOU EVER HAD YOUR VISION IMPROVED BY METHODS OTHER THAN STATED IN
QUESTIONS 8 OR 9?
HAVE YOU EVER HAD OR DO YOU NOW HAVE:
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
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?
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
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
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
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
hand or foot rashes, eczema, or dry skin
32. Asthma or wheezing
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