DD Form 2378 DoD Medical Examination Review Board (DoDMERB) Statement

DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)
STATEMENT OF HISTORY REGARDING HEADACHES

OMB No. 0704-0396
OMB approval expires
Sep 30, 2006

The public reporting burden for this collection of information is estimated to average 7 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, Executive Services Directorate (0704-0396). 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 TO DODMERB/DR, 8034 EDGERTON
DRIVE, SUITE 132, USAF ACADEMY CO 80840-2200.
PRIVACY ACT STATEMENT
AUTHORITY: Title 10, USC 133, 3012, 5031, 8013, and Executive Order 9397.
PRINCIPAL PURPOSE: To determine medical acceptability or update a medical file as part of the application process to a United States
Service Academy, Reserve Officer Training Corps (ROTC) Scholarship Program, or the Uniformed Services University of the Health
Sciences (USUHS).
ROUTINE USES: This information may be disclosed to the Coast Guard Academy and Merchant Marine Academy for applications to their
Academies.
DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection process and hamper your
candidacy. Use of the Social Security Number (SSN) is used for positive identification of records.
INSTRUCTIONS
Please provide the following information concerning your history of headaches. Be very specific in your answers. If additional space is
needed, please use the reverse side of this form.
1. HOW OFTEN HAVE YOUR HEADACHES OCCURRED DURING THE LAST 3 YEARS? (e.g., monthly, quarterly, every six months, etc.)

2. WHEN HEADACHES OCCUR, WHAT IS THEIR FREQUENCY? (e.g., once a day, twice, three times, etc.)

3. HOW LONG DO THE HEADACHES USUALLY LAST? (e.g., 1 hour, 2 hours, 6 hours, etc.)

4. HAVE YOU EVER TAKEN ANY MEDICATIONS FOR YOUR HEADACHES? IF SO, PLEASE EXPLAIN IN DETAIL (e.g., what medication,
usual dose, etc.)

5. HOW DO HEADACHES INTERFERE WITH NORMAL ACTIVITIES?

6. LIST ANY OTHER PERTINENT INFORMATION CONCERNING THIS PROBLEM.

7. HAVE YOU SEEN A PHYSICIAN FOR YOUR HEADACHES? IF SO, WHAT WERE THE FINDINGS?

8. APPLICANT
PRINTED NAME AND SIGNATURE

DD FORM 2378, MAR 2004

SOCIAL SECURITY NUMBER

PREVIOUS EDITION IS OBSOLETE.

DATE

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