Dd Form 2807-2 - Accessions Medical Prescreen Report Page 2
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7OMB No. 0704-0413
ACCESSIONS MEDICAL PRESCREEN REPORT
OMB approval expires
Oct 31, 2017
The public reporting burden for this collection of information is estimated to average 10 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, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100
(0704-0413). 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
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS.
currently valid OMB control number.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 504, 505, 507, 532, 978, 1201, 1202, and 4346; and E.O. 9397 (SSN).
PRINCIPAL PURPOSE(S): To obtain medical data for determination of medical fitness for enlistment, induction, appointment and retention for applicants
and members of the Armed Forces. The information will also be used for medical boards and separation of Service members from the Armed Forces.
ROUTINE USE(S): DoD Blanket Routine Uses found at
apply to the use of this
data.
DISCLOSURE: Voluntary, however, failure by an applicant to provide the information may result in delay or possible rejection of the individual’s application
to enter the Armed Forces. For an Armed Forces member, failure to provide the information may result in the individual being placed in a non-deployable
status.
WARNING: The information you have given constitutes an official statement. Federal law provides severe penalties (up to 5 years confinement or $10,000
fine, or both), to anyone making a false statement. If you are selected for enlistment, commission or entrance into a commissioning program based on a
false statement, you may be subject to prosecution under the Uniform Code of Military Justice or to administrative separation proceedings for discharge, and
could receive a less than honorable discharge.”
SECTION I - APPLICANT
1. LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)
2. AGE
3. DATE OF BIRTH (YYYYMMDD)
4. SOCIAL SECURITY NUMBER
7. MAX WEIGHT
5. HEIGHT (inches)
6. WEIGHT (lbs.)
8. SERVICE AND COMPONENT (X as applicable)
9. DATE (YYYYMMDD)
(lbs.)
Army
USMC
Regular
Navy
USCG
Reserve Component
USAF
Other:
National Guard
11. POSITION (If a current Federal Employee)
10. PURPOSE OF EXAMINATION (X as applicable)
12. USUAL OCCUPATION
(Job Title, Grade, Component)
Enlistment
U.S. Service Academy
Commission
ROTC Scholarship
Retention
Other (Specify)
SECTION II - MEDICAL HISTORY.
Initial each item "Yes" or "No". All "Yes" items must be fully explained in Section III (Pages 4 and 5).
CURRENTLY HAVE OR ANY HISTORY OF:
CURRENTLY HAVE OR ANY HISTORY OF:
YES
NO
YES
NO
EYES
LUNGS, CHEST WALL, PLEURA, AND MEDIASTINUM
1. Double vision
22. Asthma
2. Detached retina or surgery to repair a detached retina
23. Wheezing
3. Cataracts or surgery for cataracts
24. Shortness of breath
4. Eye surgery to improve vision (RK, PRK, LASIK, etc.)
25. Bronchitis
26. Other breathing problems worsened by exercise, weather,
5. Night blindness
pollens, etc.
6. Glaucoma
27. Used inhaler(s) or steroids for breathing problem(s)
7. Strabismus or "lazy eye" or any surgery to correct these
28. Chronic cough or frequent coughing at night
8. Any other eye condition, injury or surgery
29. Collapsed lung or other lung condition
VISION
30. History of chest, chest wall, or breast surgery
9. Worn/wear contact lenses or glasses (Bring your contact lens kit
HEART
and solution so you can remove contacts during vision testing, or
for best results remove 72 hours prior. Bring your eyeglasses no
31. Heart murmur, valve problem or mitral valve prolapse
matter how old they are.)
32. Palpitation, pounding heart or abnormal heartbeat
10. Loss of vision in either eye
33. Heart surgery
11. Color vision deficiency or color blindness
34. Pain or pressure in the chest
EARS
35. An abnormal electrocardiogram (EKG)
12. Perforated ear drum or tubes in ear drum(s)
36. Any other heart problems
13. Ear surgery, to include mastoidectomy or repair of perforated
ABDOMINAL ORGANS AND GASTROINTESTINAL SYSTEM
ear drum
14. Loss of balance or vertigo
37. Stomach, esophageal or intestinal ulcer
HEARING
38. Difficulty swallowing
15. Hearing loss or wear a hearing aid
39. Frequent indigestion or heartburn
NOSE, SINUSES, MOUTH, AND LARYNX
40. Gall bladder trouble or gallstones
16. Ear, nose, or throat trouble including tonsillectomy
41. Jaundice (except neonatal) or hepatitis (liver disease)
17. Chronic sinus infections or recurrent nose bleeds
42. Rupture/hernia
43. Surgery to remove or repair a portion of the intestine or spleen
18. Absence of, or disturbance of sense of smell
(other than the appendix)
19. Any surgery of your face, mandible or jaw
44. Chronic or recurrent intestinal problem of the small or large
DENTAL
bowel such as Irritable Bowel Syndrome, Crohn's disease,
20. Do you wear dental braces or plan to wear braces? (If so, your
Ulcerative Colitis, or Celiac disease
orthodontist must submit a letter stating that active orthodontic
45. Rectal disease, hemorrhoids, or blood from the rectum
treatment will be completed prior to active duty date: release form/
sample format can be found in the Recruiter's Medical Guide.)
46. Hemorrhoid surgery
21. Tooth or gum problems (other than cavities)
47. Bariatric surgery (weight loss surgery)
DD FORM 2807-2, MAR 2015
Page 2 of 7 Pages
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