Dd Form 2492 Dod Medical Examination Review Board (Dodmerb) Report Of Medical History Page 2

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FORM II CONTINUED
83. REMARKS. Applicant use only. Every "yes" response in items 7 through 81 must be explained in the space provided. Give specific dates and
details including names of physicians and hospitals or clinics and the current status of the condition. If additional space is required, continue on a
separate sheet and attach to this form.
84. CERTIFICATION. I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my
knowledge. I authorize any of the physicians, hospitals, or clinics mentioned above to furnish the Government a complete transcript of my
medical record for purposes of processing my application for this employment or service.
TYPED OR PRINTED NAME OF EXAMINEE/APPLICANT
SIGNATURE OF EXAMINEE/APPLICANT
DATE SIGNED
(YYYYMMDD)
85. EXAMINER'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA. Examiner shall comment on all "Yes" and blank answers,
indicating the item number before each comment. Develop by interview any additional medical history deemed important, and record significant
findings here. If additional space is required, continue on a separate sheet and attach to this form.
87. NUMBER OF
86. EXAMINER
ATTACHED
TYPED OR PRINTED NAME OF EXAMINER
SIGNATURE OF EXAMINER
DATE SIGNED
SHEETS
(YYYYMMDD)
DD FORM 2492 (BACK), MAR 2008

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