Dd Form 2792 - Family Member Medical Summary (With Instructions) Page 9

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FAMILY MEMBER/PATIENT NAME (Last, First, Middle Initial)
SPONSOR NAME
SPONSOR SSN (Last four)
MEDICAL SUMMARY - PART B
: To be completed by a Qualified Medical Professional
(Continued)
23. ARTIFICIAL OPENINGS/PROSTHETICS (X all that apply)
F99 - OTHER UNSPECIFIED OPENING
F01 - GASTROSTOMY
F05 - COLOSTOMY
YES
IF YES:
(Specify)
NO
F02 - TRACHEOSTOMY
F06 - ILEOSTOMY
F03 - CSF SHUNT
F07 - OTHER UNSPECIFIED PROSTHETICS (Specify)
F04 - CYSTOSTOMY
24. MEDICALLY INDICATED
ENVIRONMENTAL/ARCHITECTURAL CONSIDERATIONS
(as indicated in diagnostic information)
R01 - LIMITED STEPS (If Yes, please explain)
R03 - AIR CONDITIONING
R02 - COMPLETE WHEELCHAIR ACCESSIBILITY
R03a - TEMPERATURE CONTROL
R03c - POLLEN CONTROL
R04 - SINGLE STORY/LEVEL HOUSE
R03b - HEPA FILTER
R03d - AIR FILTERING
R05 - CARPET PROHIBITED
R99 - OTHER (Specify below)
(Specify and provide justifications for environmental/architectural considerations):
25. MEDICALLY NECESSARY ADAPTIVE EQUIPMENT/SPECIAL MEDICAL EQUIPMENT
(Identified in diagnostic information). (If marked, describe.)
a. TYPE OF EQUIPMENT (X)
b. DESCRIPTION
a. TYPE OF EQUIPMENT (X)
b. DESCRIPTION
L03 - APNEA HOME MONITOR
L14 - HOME VENTILATOR
L31 - COCHLEAR IMPLANT
L22 - INSULIN PUMP
L21 - CONTINUOUS POSITIVE
L32 - INTERNAL
AIRWAY PRESSURE
DEFIBRILLATOR
(CPAP) THERAPY
L33 - FEEDING PUMP
L23 - PACEMAKER
L07 - SPLINTS, BRACES,
L04 - HEARING AIDS
ORTHOTICS
L20 - HOME DIALYSIS
L08 - WHEELCHAIR
MACHINE
L99 - OTHER (Specify)
L13 - HOME NEBULIZER
L12 - HOME OXYGEN
THERAPY
26. IDENTIFY ANY LIMITATIONS FOR ACTIVITIES OF DAILY LIVING AND ANY TRAVEL LIMITATIONS
(Please explain.)
PART C - PROVIDER INFORMATION
27.a. PROVIDER PRINTED NAME OR STAMP
b. SIGNATURE
c. DATE (YYYYMMDD)
d. TELEPHONE NUMBERS (Include Area Code/Country Code)
e. OFFICIAL E-MAIL ADDRESS
f. MEDICAL SPECIALTY
(1) COMMERCIAL
(2) DSN (Military only)
DD FORM 2792, AUG 2014
Page 7 of 11 Pages

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