Dd Form 2796 Draft - Post-Deployment Health Assessment (Pdha) Page 6
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): _______________________
6.
Post-deployment general symptoms/health concerns.
List of symptoms reported as “Bothered a Lot” on Deployer Questions 11a.
through 11ee.
List of symptoms reported as “Bothered a Little” on Deployer Questions 11a.
through 11ee.
Physical symptom (PHQ-15) severity score for Deployer Questions 11a.
through 11o.
Minimal < 4
Low 5 - 9
Medium 10 - 14
High ≥ 15
Deployer’s total
_____
_____
_____
_____
a. Does deployer have evidence of high generalized post-deployment
Yes
physical symptoms (a score of ≥ 15 on the PHQ-15 physical
No
symptoms scale - deployer questions 11a. - 11o.) or is “bothered
Not answered by deployer
a lot” by specific symptoms listed in 11a. – 11ee.?
b. Based on deployer’s responses to deployer questions
Yes
(complete blocks 19 and 20)
11a. through 11ee. is a referral indicated?
No
Already under care
Already has referral
No significant impairment
Other reason (explain): ________________________
7.
Major life stressor as reported on deployer question 12.
a. Did deployer mark they have a concern or a
Yes Deployer’s concern: _________________________
difficulty with a major life stressor?
No (go to block 8)
Not answered by deployer
S A M P L E
b. If yes, ask additional questions to determine level of problem: ________________________________________________________
c. Consider need for referral. Referral indicated?
Yes
(complete blocks 19 and 20)
No
Already under care
Already has referral
No significant impairment
Other reason (explain): ________________________
8.
Self-reported history of prescription or over-the-counter medications as described on deployer question 13.
Not
Yes
Deployer
Deployer’s
Provider comments (if
answered
response
question
response
indicated)
Medications
DD FORM 2796, OCT 2015
Page 6 of 10 Pages
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business