DD Form 2807-1 Report of Medical History

REPORT OF MEDICAL HISTORY

(This information is for official and medically confidential use only and will not be released to unauthorized persons.)

OMB No. 0704-0413
OMB approval expires

The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark
Center Drive, Alexandria, VA 22350-3100 (0704-0413). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply
with a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM AS INDICATED ON PAGE 2.
PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 136, DoD Instruction 6130.03, and E.O. 9397, as amended (SSN).
PRINCIPAL PURPOSE(S): The primary collection of this information is from individuals seeking to join the Armed Forces. The information collected on this form is used
to assist DoD physicians in making determinations as to acceptability of applicants for military service and verifies disqualifying medical condition(s) noted on the
prescreening form (DD 2807-2). An additional collection of information using this form occurs when a Medical Evaluation Board is convened to determine the medical
fitness of a current member and if separation is warranted. Completed forms are covered by recruiting, medical evaluation board, and official military personnel file SORNs
maintained by each of the Services.
ROUTINE USE(S): The Blanket Routine Uses found at http://privacy.defense.gov/blanket_uses.shtml apply to this collection.
DISCLOSURE: Voluntary. However, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application to enter the
Armed Forces. An applicant's SSN is used during the recruitment process to keep all records together and when requesting civilian medical records. For an Armed Forces
member, failure to provide the information may result in the individual being placed in a non-deployable status.The SSN of an Armed Forces member is to ensure the
collected information is filed in the proper individual's record.

WARNING: The information you have given constitutes an official statement. Federal law provides severe penalties (up to 5 years confinement or a
$10,000 fine or both), to anyone making a false statement. If you are selected for enlistment, commission, or entrance into a commissioning program
based on a false statement, you can be tried by military courts-martial or meet an administrative board for discharge and could receive a less than
honorable discharge that would affect your future.
1. LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX)

2. SOCIAL SECURITY NUMBER

3. TODAY'S DATE (YYYYMMDD)

D R A F T

4.a. HOME ADDRESS (Street, Apartment No., City, State, and ZIP Code)

5. EXAMINING LOCATION AND ADDRESS (Include ZIP Code)

b. HOME TELEPHONE (Include Area Code)
7.a. POSITION (Title, Grade, Component)

X ALL APPLICABLE BOXES:
6.a. SERVICE
Army
Navy

Coast
Guard

b. COMPONENT

Marine Corps

c. PURPOSE OF EXAMINATION

Regular

Enlistment

Medical Board

Reserve

Commission

Retirement

National Guard

Retention

U.S. Service Academy

Air Force

Separation

8. CURRENT MEDICATIONS (Prescription and Over-the-counter)

Other (Specify)
b. USUAL OCCUPATION

ROTC Scholarship Program
9. ALLERGIES (Including insect bites/stings, foods, medicine or other substance)

Mark each item "YES" or "NO". Every item marked "YES" must be fully explained in Item 29 on Page 2.
HAVE YOU EVER HAD OR DO YOU NOW HAVE:

YES NO

12. (Continued)

b. Lived with someone who had tuberculosis

g. Impaired use of arms, legs, hands, or feet

c. Coughed up blood
d. Asthma or any breathing problems related to exercise, weather,

h. Swollen or painful joint(s)
i. Knee trouble (e.g., locking, giving out, pain or ligament injury, etc.)
j. Any knee or foot surgery including arthroscopy or the use of a scope

pollens, etc.

e. Shortness of breath

to any bone or joint

f. Bronchitis

k. Any need to use corrective devices such as prosthetic devices, knee

g. Wheezing or problems with wheezing

l. Bone, joint, or other deformity

brace(s), back support(s), lifts or orthotics, etc.

h. Been prescribed or used an inhaler

m. Plate(s), screw(s), rod(s) or pin(s) in any bone

i. A chronic cough or cough at night

n. Broken bone(s) (cracked or fractured)

j. Sinusitis

13.a. Frequent indigestion or heartburn

k. Hay fever

b. Stomach, liver, intestinal trouble, or ulcer

l. Chronic or frequent colds

c. Gall bladder trouble or gallstones
d. Jaundice or hepatitis (liver disease)

11.a. Severe tooth or gum trouble
b. Thyroid trouble or goiter

e. Rupture/hernia

c. Eye disorder or trouble

f. Rectal disease, hemorrhoids or blood from the rectum

d. Ear, nose, or throat trouble

g. Skin diseases (e.g. acne, eczema, psoriasis, etc.)

e. Loss of vision in either eye

h. Frequent or painful urination

f. Worn contact lenses or glasses

i. High or low blood sugar

g. A hearing loss or wear a hearing aid

j. Kidney stone or blood in urine

h. Surgery to correct vision (RK, PRK, LASIK, etc.)

k. Sugar or protein in urine
l. Sexually transmitted disease (syphilis, gonorrhea, chlamydia, genital

12.a. Painful shoulder, elbow or wrist (e.g. pain, dislocation, etc.)
b. Arthritis, rheumatism, or bursitis

YES NO

f. Foot trouble (e.g., pain, corns, bunions, etc.)

10.a. Tuberculosis

warts, herpes, etc.)

14.a. Adverse reaction to serum, food, insect stings or medicine

c. Recurrent back pain or any back problem

b. Recent unexplained gain or loss of weight

d. Numbness or tingling

c. Currently in good health (If no, explain in Item 29 on Page 2.)

e. Loss of finger or toe

DD FORM 2807-1, 20140224 DRAFT

d. Tumor, growth, cyst, or cancer
DoD exception to SF 93 approved by ICMR, August 3, 2000.

PREVIOUS EDITION IS OBSOLETE.

Page 1 of 3 Pages
Adobe Professional X

LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX)

SOCIAL SECURITY NUMBER

Mark each item "YES" or "NO". Every item marked "YES" must be fully explained in Item 29 below.
HAVE YOU EVER HAD OR DO YOU NOW HAVE:
YES NO
15.a. Dizziness or fainting spells
b. Frequent or severe headache
c. A head injury, memory loss or amnesia

a. Sensitivity to chemicals, dust, sunlight, etc.

d. Paralysis

b. Inability to perform certain motions

e. Seizures, convulsions, epilepsy or fits

c. Inability to stand, sit, kneel, lie down, etc.

f. Car, train, sea, or air sickness

d. Other medical reasons (If yes, give reasons.)

g. A period of unconsciousness or concussion
h. Meningitis, encephalitis, or other neurological problems
16.a. Rheumatic fever
b. Prolonged bleeding (as after an injury or tooth extraction, etc.)
c. Pain or pressure in the chest
d. Palpitation, pounding heart or abnormal heartbeat
e. Heart trouble or murmur
f. High or low blood pressure

20. Have you ever been treated in an Emergency Room?
(If yes, for what?)
21. Have you ever been a patient in any type of hospital? (If yes,
specify when, where, why, and name of doctor and complete
address of hospital.)
22. Have you ever had, or have you been advised to have any
operations or surgery? (If yes, describe and give age at which
occurred.)

D R A F T

17.a. Nervous trouble of any sort (anxiety or panic attacks)
b. Habitual stammering or stuttering

YES NO

19. Have you been refused employment or been unable to hold a job
or stay in school because of:

c. Loss of memory or amnesia, or neurological symptoms
d. Frequent trouble sleeping
e. Received counseling of any type
f. Depression or excessive worry
g. Been evaluated or treated for a mental condition
h. Attempted suicide
i. Used illegal drugs or abused prescription drugs
18. FEMALES ONLY. Have you ever had or do you now have:
a. Treatment for a gynecological (female) disorder
b. A change of menstrual pattern

23. Have you ever had any illness or injury other than those
already noted? (If yes, specify when, where, and give details.)
24. Have you consulted or been treated by clinics, physicians,
healers, or other practitioners within the past 5 years for
other than minor illnesses? (If yes, give complete address
of doctor, hospital, clinic, and details.)
25. Have you ever been rejected for military service for any
reason? (If yes, give date and reason for rejection.)
26. Have you ever been discharged from military service for any
reason? (If yes, give date, reason, and type of discharge;
whether honorable, other than honorable, for unfitness or
unsuitability.)

d. First day of last menstrual period (YYYYMMDD)

27. Have you ever received, is there pending, or have you ever
applied for pension or compensation for any disability
or injury? (If yes, specify what kind, granted by whom,
and what amount, when, why.)

e. Date of last PAP smear (YYYYMMDD)

28. Have you ever been denied life insurance?

c. Any abnormal PAP smears

29. EXPLANATION OF "YES" ANSWER(S) (Describe answer(s), give date(s) of problem, name of doctor(s) and/or hospital(s), treatment given and current medical
status.)

NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL PERSONNEL ONLY."

DD FORM 2807-1, 20140224 DRAFT

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LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX)

SOCIAL SECURITY NUMBER

30. EXAMINER'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician/practitioner shall comment on all positive answers in
questions 10 - 29. Physician/practitioner may develop by interview any additional medical history deemed important, and record any
significant findings here.)
a. COMMENTS

D R A F T

b. TYPED OR PRINTED NAME OF EXAMINER (Last, First, Middle Initial)

DD FORM 2807-1, 20140224 DRAFT

c. SIGNATURE

d. DATE SIGNED
(YYYYMMDD)

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