Dd Form 2807-2 - Accessions Medical Prescreen Report Page 4
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7LAST 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
LEARNING, PSYCHIATRIC, AND BEHAVIORAL (Continued)
SUPPLEMENTAL QUESTIONS (Continued)
136. Been expelled or suspended from school
154. Any recent unexplained gain or loss of weight
155. Artificial or replacement body part (eye, bone, palate, hip, knee,
137. Been kicked out or removed from your home
joint, leg, arm, etc.)
138. Been arrested or other encounters with law enforcement
156. Have you ever had any illness or injury other than those already
139. Been evaluated or treated, either with medication or counseling,
noted? (If "yes", specify when, where and give details in
for a mental condition, depression or excessive worry
Section III.)
157. Have you ever been treated in an Emergency Room? (If "yes",
140. Nervous trouble of any sort (anxiety or panic attacks)
explain in Section III.)
141. Anorexia, bulimia, or other eating disorder
158. Have you ever been a patient in any type of hospital (including
142. Habitual stammering or stuttering
being kept overnight)? (If "yes", specify when, where, why, and
name of doctor and complete address of hospital in Section III.)
143. Have you ever purposely cut or harmed yourself
159. Have you ever had, or have you been advised to have any
144. Have you ever attempted or considered suicide
operations or surgery? (If "yes", describe and give age at which
145. Used illegal drugs or abused prescription drugs
occurred in Section III.)
160. Have you ever been rejected for military Service for any
146. Have you been evaluated, treated, or hospitalized for substance
reason? (If "yes", give date and reason in Section III.)
abuse, addiction or dependence (including illegal drugs,
prescription medications or other substances)
161. Have you ever been discharged from the military Service for
any reason? (If "yes", give date, reason, and type of discharge,
147. Have you been evaluated, treated, or hospitalized for alcohol
whether honorable, other than honorable, for unfitness or
abuse, dependence, or addiction
unsuitability in Section III.)
148. Post-traumatic Stress Disorder or excessive stress requiring
162. Have you ever been refused employment or been unable to
counseling and/or medication following a traumatic experience
hold a job or stay in school because of any of the following:
149. Any other learning, psychiatric, or behavioral problems
(If "yes", answer a - d below and give reasons in Section III.)
TUMORS AND MALIGNANCIES
a. Sensitivity to chemicals, dust, sunlight, etc.
150. Tumor, growth, cyst, or cancer of any type
b. Inability to perform certain motions
MISCELLANEOUS
c. Inability to stand, sit, kneel, lie down, etc.
151. Cold injury, frostbite or cold intolerance
d. Other medical reasons
152. Heat injury, heat stroke or heat intolerance
163. Applied for and/or received disability evaluation and/or
SUPPLEMENTAL QUESTIONS
compensation for an injury or other medical conditions
(If "yes", provide details in Section III.)
153. Are you taking any medications, to include over the counter
medications (OTCs), vitamin, herbal, or nutritional supplements
164. Have you ever been denied life insurance? (If "yes", provide
(If "yes", list all in Section III.)
reason(s) in Section III.)
SECTION III - APPLICANT COMMENTS.
Explain all "Yes" answers to questions 1 - 164 above.
Begin with the Item Number. Describe answer(s) fully: provide date(s) of problem(s)/condition(s); provide names of Health Care Providers (HCPs),
Clinic(s) and/or Hospital(s) along with the City and State; explain what was done (e.g., evaluation and/or treatment); and describe your current
medical status. Attach additional sheet(s) if necessary and sign and date each additional page. Obtain and attach copies of applicable medical
evaluation and treatment records.
DD FORM 2807-2, MAR 2015
Page 4 of 7 Pages
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