Dd Form 2492 Dod Medical Examination Review Board (Dodmerb) Report Of Medical History (Page 3 of 4) in pdf

FORM III

REPORT OF MEDICAL EXAMINATION

_____________________________________________________________________________________________

Last Name

First Name

Middle Name

Age

INSTRUCTION FOR MEDICAL EXAMINER

The standard for acceptance into the Virginia Tech Corps of Cadets is the ability

to fully participate in training activities. This includes strenuous physical exercise and activities which may occur in a hot and

humid environment. Defects that have the potential to result in illness or injury brought on by physical exercise should be

identified and other condition(s) which could interfere with full and unrestricted participation need to be listed and evaluated.

Conditions that will or are likely to require treatment, particularly unresolved injuries and recurrent illnesses also must be listed. It

is imperative that ALL the listed tests be done and all questions answered.

_____________________________________________________________________________________________

Height: __________ ft __________ in

Weight: __________ lbs

Obese?: Yes _____ No _____

Pulse: __________ Blood Pressure: __________ / __________

Eyes, ears, nose: ______________________________________________________________________________________________

Vision

Wear glasses: Yes _____ No _____

Wears contacts: Yes _____ No _____

Vision in both eyes: Yes _____ No _____

Lungs __________ Heart __________ Abdomen __________ Genitalia __________ Hernia __________ Spine __________

Orthopedic oriented examination (evaluation of conditions that may limit involvement in physical activities (i.e., sports, physical

training, etc.):

Body Symmetry: _______________ Cervical Spine Motion: _______________ Upper Body Flexibility: _______________

Lower Body Flexibility: _______________ Knee Stability: _______________ Other: _________________________

It is the opinion of the medical examiner that this examinee has / does not have a communicable (or other) disease, injury, or other

condition that will restrict his / her participation in the Corps of Cadets Program. Yes _____ No _____

Could this cadet participate in daily calisthenics / physical fitness training for one week (running 1.5 miles, push-ups, sit-ups, other

physical exercises)? Yes _____ No _____

If no, please indicate any specific limitations the cadet should observe: _________________________________________________

____________________________________________________________________________________________________________

________________________________________________________

___________________________________

Signature

Date

________________________________________________________

Typed or printed name of medical examiner

Dd Form 2492 Dod Medical Examination Review Board (Dodmerb) Report Of Medical History Page 3