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

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SECTION II

83. REMARKS. 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. Continue on a separate sheet and attach

to this form if additional space is needed.

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

SIGNATURE

DATE SIGNED

(YYYYMMDD)

NOTE: HAND TO THE PHYSICIAN OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL PERSONNEL ONLY."

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 needed,

continue on a separate sheet and attach to this form.)

87. NUMBER OF

86. PHYSICIAN OR EXAMINER

ATTACHED

TYPED OR PRINTED NAME

SIGNATURE

DATE SIGNED

SHEETS

(YYYYMMDD)

DD FORM 2492 (BACK), SEP 2000