Dd Form 2796 Draft - Post-Deployment Health Assessment (Pdha) Page 2
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10This 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
2.
Compared to before this deployment, how would you rate your health in general now?
Much better now than before I deployed
Somewhat better now than before I deployed
About the same as before I deployed
Somewhat worse now than before I deployed
Please explain: ___________________________________________________
Much worse now than before I deployed
Please explain: ___________________________________________________
3.
How often did you smoke tobacco (for example cigarettes, cigars, pipe, or hookah) during your deployment?
Just about every day
Some days
Not at all
Yes
No
4.
Were you wounded, injured, assaulted or otherwise hurt during your deployment?
If yes, are you still having any problems or concerns related to this event?
Yes
No
If yes, please explain: __________________________________________________________________________________________
5.
During your deployment:
a. Did you ever feel like you were in great danger of being killed?
Yes
No
b. Did you encounter dead bodies or see people killed or wounded during this deployment?
Yes
No
c. Did you engage in direct combat where you discharged a weapon?
Yes
No
6.
How many times during your deployment did you visit a health care provider for a medical or dental health problem/concern?
No visits
1 visit
2-3 visits
4-5 visits
6 or more
7.
During this deployment did you receive care for combat stress or a mental health problem/concern?
Yes
No
If yes, please explain: ___________________________________________________________________________________________
Yes
No
8.
During this deployment, did you have to spend one or more nights in a hospital as a patient?
S A M P L E
Reason/dates: _________________________________________________________________________________________________
9.
During the PAST MONTH, how difficult have physical health problems (illness or injury) made it for you to do your work or other
regular daily activities?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
10.a. During this deployment, did any of the following events happen to you? (Mark all that apply)
(1) Blast or explosion (e.g., IED, RPG, EFP, land mine, grenade, etc.)?
Yes
No
If yes, please estimate your distance from the closest blast or explosion:
Less than 25 meters (82 feet)
25-50 meters (82-164 feet)
50-100 meters (164-328 feet)
More than 100 meters (328 feet)
(2) Vehicular accident/crash (any vehicle including aircraft)?
Yes
No
(3) Fragment wound or bullet wound?
a. Head or neck
Yes
No
b. Rest of body
Yes
No
(4) Other injury (e.g., sports injury, accidental fall, etc.)?
Yes
No
If yes to any of the above, please explain: ___________________________________________________________________________
10.b. As a result of any of the events in 10.a., did you receive a jolt or blow to your head that IMMEDIATELY resulted in:
(1) Losing consciousness (“knocked out”)?
Yes
No
If yes, for about how long were you knocked out?
Less than 5 min
5-30 min
more than 30 min
(2) Losing memory of events before or after the injury?
Yes
No
(3) Seeing stars, becoming disoriented, functioning
differently, or nearly blacking out?
Yes
No
10.c. How many total times during this deployment did you receive a blow or jolt to your head?
(only answer if you had a yes to any of the questions on 10a.)
0
1
2
3
more than 3 (list number of times) _____________
DD FORM 2796, OCT 2015
Page 2 of 10 Pages
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