Dd Form 2796 Draft - Post-Deployment Health Assessment (Pdha) Page 5
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10This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
Health Care Provider Only – Provider Review, Interview, Assessment, and Recommendations:
Deployer reports arriving in theater on: _______________________
Deployer reports departing theater on: _______________________
1.
Address concerns identified on deployer questions 1 and 2.
Deployer
Deployer’s
Provider
Not
Deployer
indicated
(if
response
comments
answered
or concern
question
concern
indicated)
Self health rating
Change in health post-deployment
2.
Address wounds, injuries, assaults, etc., occurring during deployment as reported on deployer question 4.
a. Did deployer mark that he/she is still having a problem
Yes
or concern related to a wound, injury, or assault that
No (go to block 3)
occurred during their deployment?
Not answered by deployer
b. Refer for evaluation?
Yes (complete blocks 19 and 20)
No
Already under care
Already has referral
No significant impairment
Other reason (explain): _________________________
3.
Deployment experiences as reported in deployer question 5. Consider in overall assessment; ask follow-up questions as indicated.
Not
Yes
Deployer
Provider comments (if
answered
response
question
indicated)
Danger of being killed
Encountered bodies or saw people killed or wounded
S A M P L E
In direct combat and discharged weapon
4.
Address concerns identified on deployer questions 6 through 9.
Deployer
Deployer’s
Not
Deployer
Provider comments (if
indicated
response
answered
or concern
question
indicated)
concern
Health care visits during deployment
Care for combat stress/mental health
Hospitalized during deployment
Physical limitations/problems
5.
Deployment injury and concussion risk assessment.
a. Did deployer have an injury based on their
Yes
responses to question 10.a.?
No (go to block 6)
b. Did deployer have a possible concussion based on
Yes
their responses to questions 10.a. through 10.c.?
No (go to block 6)
c. Evaluate injury history and concussion-related experiences and symptoms.
Refer for evaluation?
Yes (complete blocks 19 and 20)
No
Already under care
Already has referral
No significant impairment
Other reason (explain): ________________________
DD FORM 2796, OCT 2015
Page 5 of 10 Pages
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