Dd Form 2792 - Family Member Medical Summary (With Instructions) Page 7

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FAMILY MEMBER/PATIENT NAME (Last, First, Middle Initial)
SPONSOR NAME
SPONSOR SSN (Last four)
MEDICAL SUMMARY
: To be completed by a Qualified Medical Professional
(Continued)
PART A - PATIENT STATUS
(Continued)
12. SECONDARY DIAGNOSIS 2
a. DIAGNOSIS
b. CODE
.
13. MEDICATION HISTORY
(Associated with secondary diagnosis)
a. CURRENT MEDICATION(S)
b. DOSAGE
c. FREQUENCY
14. HOSPITAL SUPPORT FOR THE LAST 12 MONTHS
(Associated with secondary diagnosis)
a. NUMBER OF ER VISITS/URGENT
d. NUMBER OF OUTPATIENT
b. NUMBER OF HOSPITALIZATIONS
c. NUMBER OF ICU ADMISSIONS
CARE VISITS
VISITS
15. PROGNOSIS
(X one)
EXCELLENT
GOOD
FAIR
POOR
GUARDED
UNSTABLE
NON-COMPLIANT
16. TREATMENT PLAN FOR THIS DIAGNOSIS
(Medical, mental health, surgical procedures or therapies planned or recommended over the next three years.
For cancer patients, include date of diagnosis, types of treatment, responses to treatment, if treatment is active and if treatment is completed.)
17. SECONDARY DIAGNOSIS 3
a. DIAGNOSIS
b. CODE
.
18. MEDICATION HISTORY
(Associated with secondary diagnosis)
a. CURRENT MEDICATION(S)
b. DOSAGE
c. FREQUENCY
19. HOSPITAL SUPPORT FOR THE LAST 12 MONTHS
(Associated with secondary diagnosis)
a. NUMBER OF ER VISITS/URGENT
d. NUMBER OF OUTPATIENT
b. NUMBER OF HOSPITALIZATIONS
c. NUMBER OF ICU ADMISSIONS
CARE VISITS
VISITS
20. PROGNOSIS
(X one)
EXCELLENT
GOOD
FAIR
POOR
GUARDED
UNSTABLE
NON-COMPLIANT
21. TREATMENT PLAN FOR THIS DIAGNOSIS
(Medical, mental health, surgical procedures or therapies planned or recommended over the next three years.
For cancer patients, include date of diagnosis, types of treatment, responses to treatment, if treatment is active and if treatment is completed.)
DD FORM 2792, AUG 2014
Page 5 of 11 Pages

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