Dd Form 2796 Draft - Post-Deployment Health Assessment (Pdha) Page 7
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10This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
9.
Alcohol use as reported in deployer question 14.
a. Deployer’s AUDIT-C screening score was ______. (If score between
Not answered
0-4 (men) or 0-3 (women) nothing required, go to block 10).
Number of drinks per week:
Maximum number of drinks per occasion:
_____________
_____________
Based on the AUDIT-C score and assessment of alcohol use, follow the guidance below:
Alcohol Use Intervention
Matrix
AUDIT-C Score
AUDIT-C Score
Men 5 - 7
Assess Alcohol Use
Men and Women ≥
Women 4 - 7
8
Alcohol use WITHIN recommended limits:
Advise patient to stay below
Men: ≤ 14 drinks per week OR ≤ 4 drinks on any occasion
recommended limits
Refer if indicated for further evaluation
Women: ≤ 7 drinks per week OR ≤ 3 drinks on any occasion
AND
Alcohol use EXCEEDS recommended limits:
conduct BRIEF counseling*
Conduct BRIEF counseling*
Men: > 14 drinks per week or > 4 drinks on any occasion
AND
consider referral for further evaluation
Women: > 7 drinks per week or > 3 drinks on any occasion
* BRIEF counseling: Bring attention to elevated level of drinking; Recommend limiting use or abstaining; Inform about the effects of alcohol
on health; Explore and help/support in choosing a drinking goal; Follow-up referral for specialty treatment, if indicated.
b. Referral indicated for evaluation?
Yes (complete blocks 19 and 20)
No Provide education/awareness as needed.
State reason if AUDIT-C score was 8+:
S A M P L E
Already under care
Already has referral
No significant impairment
Other reason (explain): ________________________
10. PTSD screening as reported in deployer question 15.
a. Are two or more of the deployer’s responses
Yes
to questions 15a. through 15d. “yes?”
No (go to block 11)
Not answered by deployer
b. If yes, ask additional questions to determine extent 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): ________________________
11. Depression screening as reported in deployer question 16.
a. Did deployer mark “more than half the days” or
Yes
“nearly every day” on question 16a. or 16b.?
No (go to block 12)
Not answered by deployer
b. If yes, ask additional questions to determine extent of problem; briefly describe results: _____________________________________
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): ________________________
DD FORM 2796, OCT 2015
Page 7 of 10 Pages
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