Dd Form 2796 Draft - Post-Deployment Health Assessment (Pdha) Page 3
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): _______________________
11. During the PAST MONTH, how much have you been bothered by any of the following problems?
Not bothered at
Bothered a
Bothered a
Symptom
all
little
lot
a. Stomach pain
b. Back pain
c. Pain in the arms, legs, or joints (knees, hips, etc.)
d. Menstrual cramps or other problems with your periods (Women only)
e. Headaches
f.
Chest pain
g. Dizziness
h. Fainting spells
i.
Feeling your heart pound or race
j.
Wheezing, shortness of breath, or difficulty breathing (other than asthma)
k. Pain or problems during sexual intercourse
l.
Constipation, loose bowels, or diarrhea
m. Nausea, gas, or indigestion
n. Feeling tired or having low energy
o. Trouble sleeping
p. Trouble concentrating on things (such as reading a newspaper or watching television)
q. Memory problems
r.
Balance problems
s. Noises in your head or ears (such as ringing, buzzing, crickets, humming, tone, etc.)
t.
Trouble hearing
u. Sensitivity to bright light
v. Becoming easily annoyed or irritable
w. Fever
x. Cough lasting more than 3 weeks
y. Numbness or tingling in the hands or feet
S A M P L E
z. Hard to make up your mind or make decisions
aa. Watery, red eyes
bb. Dimming of vision, like the lights were going out
cc. Skin rash and/or lesion
dd. Pain with urination, frequency of urination, or strong urge to urinate
ee. Bleeding gums, tooth pain, or broken tooth
12. a. Over the PAST MONTH, what major life stressors have
None or
you experienced that are a cause of significant concern
Please list and explain: ___________________________
or make it difficult for you to do your work, take care of
things at home, or get along with other people (for example,
______________________________________________
serious conflicts with others, relationship problems,
or a legal, disciplinary or financial problem)?
______________________________________________
Yes
No
b. Are you currently in treatment or getting professional
help for this concern?
13. What prescription or over-the-counter medications (including
Please list:
____________________________________
herbals/supplements) for sleep, pain, combat stress, or a
____________________________________________________
mental health problem are you CURRENTLY taking?
None
14. a. How often do you have a drink containing alcohol?
Never
Monthly or less
2-4 times a month
2-3 times per week
4 or more times a week
b. How many drinks containing alcohol do you have on a typical day when you are drinking?
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
c. How often do you have six or more drinks on one occasion?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
15. Have you ever had any experience that was so frightening, horrible, or upsetting that, in the PAST MONTH, you:
a. Have had nightmares about it or thought about it when you did not want to?
Yes
No
b. Tried hard not to think about it or went out of your way to avoid situations that remind you of it?
Yes
No
c. Were constantly on guard, watchful or easily startled?
Yes
No
d. Felt numb or detached from others, activities, or your surroundings?
Yes
No
DD FORM 2796, OCT 2015
Page 3 of 10 Pages
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business