Dd Form 2796 Draft - Post-Deployment Health Assessment (Pdha) Page 4
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10This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
16. Over the LAST 2 WEEKS, how often have you been bothered by the following problems?
Not at all
Few or several days
More than half the days
Nearly every day
a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
17. Are you worried about your health because you believe you were
Yes
No
exposed to something in the environment while deployed?
If yes, please explain: ___________________________________________________________________________________________
18. Do you think you were exposed to any chemical, biological,
Yes
No
or radiological warfare agents during this deployment?
If yes, please explain: __________________________________________________________________________________________
19. Were you in a vehicle hit by a depleted uranium (DU) round;
Yes
No
inside a destroyed vehicle that contained DU;
Don’t know
or closely inspect such a vehicle?
If yes, please explain: __________________________________________________________________________________________
20. Were you told to take medicines to prevent malaria?
Yes
No
If yes, please indicate which medicines you took and whether you took all pills as directed. (Mark all that apply)
Anti-malarial medications received
Took all pills?
Chloroquine (Aralen®)
Yes No
Doxycycline (Vibramycin®)
Yes No
Malarone®
Yes No
Mefloquine (Lariam®)
Yes No
Primaquine
Yes No
Other: __________________
Yes No
S A M P L E
Given pills but do not
Yes No
know drug name
21. Were you bitten or scratched by an animal during your deployment?
Yes
No
If yes, please explain what kind of animal was involved, your injury, and what happened:
___________________________________________________________________________________
___________________________________________________________________________________
22. Would you like to schedule an appointment with a health care provider to discuss any health concern(s)?
Yes
No
23. Are you interested in receiving information or assistance for a stress, emotional or alcohol concern?
Yes
No
Yes
No
24. Are you interested in receiving assistance for a family or relationship concern?
25. Would you like to schedule a visit with a chaplain or a community support counselor?
Yes
No
DD FORM 2796, OCT 2015
Page 4 of 10 Pages
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