Dd Form 2807-2 - Accessions Medical Prescreen Report Page 3

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LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)
SOCIAL SECURITY NUMBER (Last 4)
SECTION II - MEDICAL HISTORY
(Continued). Initial each item "Yes" or "No". All "Yes" items must be fully explained in Section III.
CURRENTLY HAVE OR ANY HISTORY OF:
YES
NO
CURRENTLY HAVE OR ANY HISTORY OF:
YES
NO
FEMALES ONLY:
SKIN AND CELLULAR
48. A change of menstrual pattern (other than pregnancy)
93. Acne or psoriasis
49. Pregnancy, abortion or miscarriage
94. Eczema
50. Any abnormal PAP smear(s)
95. Atopic dermatitis
51. Date of last PAP smear (YYYYMMDD)
96. Large or painful scars
52. Diagnosed with endometriosis or ovarian cysts
97. Any other skin problems
53. Evaluation, treatment or surgery for any other gynecological
BLOOD AND BLOOD FORMING TISSUES
(female) disorder
98. Anemia
54. Sexually transmitted disease (syphilis, gonorrhea, chlamydia,
99. Blood clots requiring blood thinner medicine
genital warts, herpes, etc.)
55. First day of last menstrual period (YYYYMMDD)
100. Absence or removal of the spleen
MALES ONLY:
101. Prolonged bleeding (after an injury or tooth extraction)
56. Missing a testicle, testicular implant, or undescended testicle
102. Any other blood or circulation problems
57. Variocele, hydrocele, or any scrotal mass, swelling or pain
SYSTEMIC
58. Prostate problems
103. Adverse reaction to medication (describe reaction in Section III)
59. Sexually transmitted disease (syphilis, gonorrhea, chlamydia,
104. Adverse reaction to serum, insect stings, or tree nuts
genital warts, herpes, etc.)
105. Allergy to common foods (milk, eggs, fish, meat, etc.)
URINARY SYSTEM
106. Allergy to wool, latex, or other material
60. Missing a kidney
107. Tuberculosis or lived with someone who had tuberculosis
61. Kidney stone, infection or disease
108. Positive test for tuberculosis (PPD or blood test)
62. Kidney or urinary tract surgery of any kind
109. Malaria
63. Blood or protein in urine
110. Disorder(s) of your immune system (including HIV)
64. Painful or difficult urination
111. Car, train, sea, or air sickness
65. Bedwetting or treatment for bedwetting (after childhood)
ENDOCRINE AND METABOLIC
66. Hernia
112. Thyroid trouble or goiter
SPINE AND SACROILIAC JOINTS
113. High or low blood sugar
67. Recurrent back pain or back problem
114. Diabetes or told that you should be tested for diabetes
68. Herniated disk
NEUROLOGIC
69. Recurrent neck pain
115. Cerebrovascular incident (stroke)
70. Back or neck surgery
116. Frequent or severe headaches, including migraines
71. Abnormal curvature of your spine (any part)
117. Taking medication to prevent headaches
UPPER EXTREMITIES
118. Lost time from work or school due to frequent or severe
72. Painful shoulder, elbow, wrist, hand or fingers
headaches
73. Dislocated shoulder, elbow, wrist, hand or fingers
119. A skull fracture
LOWER EXTREMITIES
120. A head injury, memory loss, or amnesia
74. Foot trouble (e.g., pain, corns, bunions, warts, ingrown toenails,
121. A period of unconsciousness or concussion
etc.)
122. Loss of memory or amnesia, or neurological symptoms
75. Knee trouble (e.g., locking, giving out, or ligament injury, etc.)
123. Paralysis
76. Painful hip, knee, ankle, foot or toes
124. Meningitis, encephalitis, or other neurological problems
77. Dislocated hip, knee, ankle, foot or toes
125. Seizures, convulsions, epilepsy or fits
MISCELLANEOUS CONDITIONS OF THE EXTREMITIES
126. Dizziness or fainting spells
78. Bone, joint, or other orthopedic deformity
127. Any other neurologic problems
79. Loss of finger or toe, or extra finger or toe
SLEEP DISORDERS
80. Loss of the ability to fully flex (bend) or fully extend a finger, toe,
128. Sleepwalking or narcolepsy
or other joint
81. Impaired use of arms, hands, legs, or feet (any reason)
129. Frequent trouble sleeping
82. Arthritis, rheumatism, or bursitis
130. Sleep apnea or severe snoring
83. Any swollen joint(s)
LEARNING, PSYCHIATRIC, AND BEHAVIORAL
131. Evaluated or treated for Attention Deficit Disorder (ADD) or
84. Surgery on any joint/bone (including arthroscopy)
Attention Deficit Hyperactivity Disorder (ADHD)
85. Plate(s), screw(s), rod(s) or pin(s) in any bone
132. Taken (or taking) medication, drugs, or any substance to
86. Pain or swelling at the site of an old fracture
improve attention, behavior, or physical performance
133. Diagnosed with a learning disorder, to include dyslexia
87. Any need to use corrective devices such as prosthetic devices,
knee brace(s), back support(s), lifts or orthotics
134. Received counseling of any type
88. Any other orthopedic, muscle, or sports injury problems
135. Seen a psychiatrist, psychologist, social worker, counselor or
other professional for any reason (inpatient or out-patient)
VASCULAR
including counseling or treatment for school, adjustment, family,
89. High or low blood pressure
marriage, divorce, depression, anxiety, or treatment of alcohol,
drug or substance abuse (Applicant or recruiter will request
90. Raynaud's phenomenon or disease
sealed medical supporting documents from health care pro-
91. Deep Vein Thrombosis (blood clot; leg or elsewhere)
viders marked "CONFIDENTIAL: MEPS MEDICAL DEPART-
MENT" and submit directly to MEPS medical personnel.)
92. Pulmonary embolism (blood clot in lung)
DD FORM 2807-2, MAR 2015
Page 3 of 7 Pages

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