Dd Form 2796 Draft - Post-Deployment Health Assessment (Pdha) Page 10
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
18. Deployer issues with this assessment (mark as
20. Recommended
Within
Within
Within
< Mark all that apply
referral(s)
appropriate):
Deployer declined to complete form
24 hours
7 days
30 days
deployer does not
even if
Deployer declined to complete interview/assessment
desire>
a. Primary Care, Family Practice,
Internal Medicine
Assessment and Referral: After review of deployer’s responses
b. Behavioral Health in Primary Care
and interview with the deployer, the assessment and need for
c. Mental Health Specialty Care
further evaluation is indicated in blocks 19 through 22.
d. Dental
e. Other specialty care:
19. Summary of provider’s
identified
concerns needing
Yes
No
Audiology
referral < Mark all that
Dermatology
apply>
a. None Identified
OB/GYN
b. Physical health
Physical Therapy
c. Dental health
TBI/Rehab Med
d. Concussion
Podiatry
e. Mental health symptoms
Other, list
f. Alcohol use
f. Case Manager / Care Manager
g. PTSD symptoms
g. Substance Abuse Program
h. Depression symptoms
h. Immunization clinic
i. Environment/work exposure
i. Laboratory
j. Depleted uranium
j. Other, list:
S A M P L E
k. Malaria prophylaxis
l. Risk of self-harm
21. Comments: _________________________________________
m. Risk of violence
______________________________________________________
n. Other, list:
______________________________________________________
______________________________________________________
22. Address requests as reported on deployer questions 22 through 25.
Not
Yes
Deployer
Comments (if
answered
response
question
indicated)
Request medical appointment
Request info on stress/emotional/alcohol
Family/relationship concern assistance
Chaplain/counselor visit request
23. Supplemental services recommended / information
provided
Appointment Assistance
Family Support
Information on post-deployment blood specimen requirement
Military One Source
Contract Support: _____________________________________
TRICARE Provider
Community Service: ___________________________________
VA Medical Center or Community Clinic
Chaplain
Vet Center
Health Education and Information
Other, list:
Health Care Benefits and Resources Information
In Transition
Provider’s Name: ___________________________________________
Date (dd/mmm/yyyy) _____________________________
Title:
MD or DO
PA
Nurse Practitioner
Adv Practice Nurse
IDMT
IDC
IDHS
I certify that this review process has been completed.
This visit is coded by DOD0212.
DD FORM 2796, OCT 2015
Page 10 of 10 Pages
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business