Dd Form 2795 - Privacy Act Statement (Sample) - Pre-Deployment Health Assessment Page 2
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7This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
1.
Overall, how would you rate your health during the PAST MONTH?
Excellent
Very Good
Good
Fair
Poor
Yes For what reason? ___________________________
2.
Are you CURRENTLY on a profile, limited duty, waiting on a
No
MOS/Medical Retention Board (MMRB) decision, or being
Don’t know
referred to a medical evaluation board (MEB) or physical
evaluation board (PEB)?
Just about every day
3.
How often do you smoke tobacco (for example
Some days
cigarettes, cigars, pipe or hookah)?
Not at all
Please explain: _________________________________
4.
What problems, questions or concerns do you have
None
about your medical, dental, or mental health?
FEMALES ONLY – Are you pregnant or is
Don’t know
5.
Yes
there a chance you could be pregnant?
No
Yes Please explain: ____________________________
6.
In the PAST YEAR did you receive care
No
for a head injury?
Please list: ____________________________________
7.
What prescription or over-the- counter medications
(including herbals/supplements) for sleep, pain,
combat stress, or mental health conditions or
__________________________________________
None
concerns are you CURRENTLY taking?
Yes Please explain: ____________________________
8.
In the PAST YEAR did you receive care for any mental health
No
condition or concern such as, but not limited to post traumatic
stress disorder (PTSD),depression, anxiety disorder, alcohol
abuse or substance abuse?
9.
During the PAST MONTH, how much have you been bothered by any of the following problems?
Symptom
Not bothered at all Bothered a little
Bothered a lot
a. Noises in your head or ears (such as ringing, buzzing, crickets, humming, tone, etc.)
b. Trouble hearing
10. a. How often do you have a drink containing alcohol?
Never
Monthly or less
2-4 times a month
2-3 times per week
4 or more times a week
b. How many drinks containing alcohol do you have on a typical day when you are drinking?
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
c. How often do you have six or more drinks on one occasion?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
11. Have you ever had any experience that was so frightening, horrible, or upsetting that, in the PAST MONTH, you:
Yes
No
a. Have had nightmares about it or thought about it when you did not want to?
Yes
No
b. Tried hard not to think about it or went out of your way to avoid situations that remind you of it?
Yes
No
c. Were constantly on guard, watchful or easily startled?
Yes
No
d. Felt numb or detached from others, activities, or your surroundings?
NOTE: If 2 or more items on 11a. through 11d. are marked yes, continue to answer items 11e. through 11v.
DD FORM 2795, SEP 2012
Page 2 of 7 Pages
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