DD Form 2807-2 Accessions Medical History Report

INSTRUCTIONS FOR COMPLETING DD FORM 2807-2,
ACCESSIONS MEDICAL HISTORY REPORT
1. This form is to be completed by each individual who requires medical processing in accordance with Department of Defense Instruction (DODI) 6130.03,
“Physical Standards for Appointment, Enlistment, or Induction” and DODI 1304.02, “Accession Processing Data Collection Forms.” This form must be completed
by the applicant with the assistance of the recruiter, parent(s), or guardian, as needed.
2. Replaces the existing medical prescreen form (DD Form 2807-2, MAR 2015) and the DoD Medical Examination Review Board Report of Medical History (DD
Form 2492, MAR 2008). Additional questions have been added to improve its usefulness to the accessions medical pre-screening process. The questions are
intended to provide the U.S. Military Entrance Processing Command (USMEPCOM) and Department of Defense Medical Examination Review Board (DoDMERB)
with health history information necessary to identify conditions commonly related to medical causes for separation during basic and follow-on training (per P.L.
105-85, Div. A, Title V, S 532).
3. Use of medical history information facilitates efficient, timely, and accurate medical processing of individuals applying for Service in the United States Armed
Forces or United States Coast Guard. Positive responses do not automatically result in disqualification but are necessary to prompt further explanation that will
be used to determine medical qualification. Medical history information assists USMEPCOM/DoDMERB medical personnel in the medical prescreening of
applicants. Accurate responses to all questions are critical and all positive responses must be fully explained. Applicant responses to questions may be verified
using electronically obtained medical history by the USMEPCOM/DoDMERB. Medical history information will be used by the Department of Defense for continuity
of care purposes if and when an applicant accesses into the Armed Forces or Coast Guard. Supporting medical information in the form of historical medical
records may also be attached to the Service member’s medical record. Medical history information collected by the USMEPCOM/DoDMERB during accession
medical processing will serve as the foundation for a Service member’s lifecycle electronic medical treatment.

4. If processing at a MEPS: The completed DD Form 2807-2 along with all substantiating and supporting medical documents must be delivered to USMEPCOM
for review prior to scheduling the applicant for medical examination. All documents must be submitted for review in accordance with standards below. After
review, the Military Entrance Processing Station (MEPS) will notify the Recruiting Service of the applicant’s status.
- 1 processing day prior for applicants with no positive medical history (all items marked “NO” with the exception of items 9 (glasses/contacts), 11 (defective
color vision), and 20 (braces) which can be “YES”).
- 2 processing days prior; for applicants with ANY positive medical history (other than those noted above) and 5 OR LESS single-sided pages of supporting
medical documents.

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- 3 processing days prior; for applicants with ANY positive medical history (other than those noted above) and MORE THAN 5 single-sided pages of supporting
medical documents.
Secure electronic submission is preferable; if not feasible bring/mail to the nearest MEPS which can be found at http://www.mepcom.army.mil/battalions/
index.html. All supporting medical documentation must be present with the DD Form 2807-2 to meet the above timeframes for review. After review by a
USMEPCOM provider, appropriate processing notification will be made.

5. If processing at a MEPS: If an applicant has been seen by any Health Care Provider (HCP) and/or has been hospitalized for any reason, medical records/
documentation must be obtained and submitted along with a medical release to USMEPCOM. Provide all medical documents via secure electronic submission (if
possible) to the nearest MEPS. If hand-carried or mailed, ensure they are sealed in an envelope marked: “CONFIDENTIAL: MEPS MEDICAL DEPARTMENT".
a. If the applicant was evaluated and/or treated on an out-patient basis, obtain a copy of actual treatment records of the private medical doctor/HCP including:
(1) office or clinic assessment and progress notes, including the initial assessment documents, subsequent evaluation and treatment documents, and record
of date when released from care to full, unrestricted activity;
(2) emergency room (ER) report(s);
(3) study reports (e.g. x-ray, magnetic resonance imaging (MRI), Computerized Tomography (CT), etc.);
(4) procedure reports (e.g., arthroscopy, electroencephalogram (EEG; brain wave test), echocardiogram (ultrasound of the heart), etc.);
(5) pathology reports (e.g., tissue specimens sent to lab for microscopic diagnosis, abnormal PAP smear cytology, etc.);
(6) specialty consultation records (e.g., neurologist, cardiologist, OB/GYN, gastroenterologist, orthopedic surgeon, pulmonologist, allergist, etc.).
b. If the applicant was hospitalized, obtain a copy of the inpatient hospital record, to include (if any): ER report, admission history and physical, study reports,
procedure reports, operative report (example: surgery to bone or joint), pathology report, specialty consultation reports, and discharge summary.
c. If an applicant has been diagnosed or treated for any attention disorder (Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity Disorder (ADHD),
etc.), academic skills or perceptual defect, or had an Individualized Education Plan or 504 Plan, call/contact the MEPS medical department for additional
instructions.
d. Obtain any and all documents relating to any evaluation, treatment or consultation with a psychiatrist, psychologist counselor, or therapist, on an inpatient or
out-patient basis for any reason, including but not limited to counseling or treatment for adjustment or mood disorder, family or marriage problems, depression,
treatment or rehabilitation for alcohol, drug, or substance abuse.
6. MEPS Chief Medical Officers (CMOs) or DoDMERB may locally modify the above instructions and instruct recruiters on what supporting medical documents
they require to complete the DD Form 2807-2 medical prescreen review, if doing so enhances the efficiency of medical processing and is consistent with DODI
6130.03 and USMEPCOM/DoDMERB guidance.
7. If all attempts to obtain required substantiating and supporting medical documents fail, the recruiter must contact the appropriate medical department, MEPS
medical department for enlistment applicants and DoDMERB for officer applicants, for guidance prior to submitting an incomplete medical prescreen packet.

DD FORM 2807-2, 20180409 DRAFT

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OMB No. 0704-0413
OMB approval expires

ACCESSIONS MEDICAL HISTORY REPORT

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 the burden estimate or burden reduction
suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. (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 ADDRESS.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 504, Persons not qualified; 10 U.S.C. 505, Regular components: qualifications, term, grade; 10 U.S.C. 507, Extension of enlistment for members
needing medical care or hospitalization; 10 U.S.C. 532, Qualifications for original appointment as a commissioned officer; 10 U.S.C. 978, Drug and alcohol abuse and dependency:
testing of new entrants; 10 U.S.C. 1201, Regulars and members on active duty for more than 30 days: retirement; 10 U.S.C. 1202, Regulars and members on active duty for more than
30 days: temporary disability retired list; 10 U.S.C. 4346, Cadets: requirements for admission; DoD Directive 1145.2, United States Military Entrance Processing Command; and E.O.
9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To obtain medical data for determination of medical fitness for enlistment, induction, appointment and retention for applicants and members of the Armed
Forces. The information will also be used for medical boards and separation of Service members from the Armed Forces.
ROUTINE USE(S): The routine uses are listed in the applicable system of records notice, A0601-270 USMEPCOM DoD, U.S. Military Processing Command Integrated Resources
System (USMIRS), located at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570661/a0601-270-usmepcom-dod/
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.
For an Armed Forces member, failure to provide the information may result in the individual being placed in a non-deployable status.
WARNING: The information you have given constitutes an official statement. Federal law provides severe penalties (up to 5 years confinement or $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 may be subject to prosecution under the Uniform Code of
Military Justice or to administrative separation proceedings for discharge, and could receive a less than honorable discharge.”

SECTION I - APPLICANT
1. LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

6. HEIGHT
(inches)

5. (X one)

7. WEIGHT
(lbs.)

a. SEX (at birth) b. GENDER

8.a. SERVICE (X as applicable)

4.a. SOCIAL SECURITY NUMBER

b. DoD ID NUMBER (If
applicable)

b. COMPONENT (X as applicable)

3. DATE (YYYYMMDD)

Army

USMC

Regular

USCG

Reserve Component

Other:

National Guard

Male

Male

Navy

Female

Female

USAF

10. PURPOSE OF EXAMINATION (X as applicable)

3. DATE OF BIRTH
(YYYYMMDD)

2. AGE

11. POSITION (If a current Federal Employee) (Job Title, Grade, Component)

Enlistment

U.S. Service Academy

Commission

ROTC Scholarship

Retention

Other (Specify)

12. USUAL OCCUPATION

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SECTION II - AUTHORIZATION STATEMENT

I (we), the undersigned:
l Have read and understand the warning and penalties that are associated with providing a false statement.
l Certify the information on this form is true and complete to the best of my knowledge and belief, and no person has advised me to conceal or falsify any information about my physical and mental history.
l Authorize and understand that a physical examination is part of the accession evaluation, may require several visits to the Military Entrance Processing Station (MEPS), and Department of Defense Medical
Examination Review Board (DoDMERB) contracted medical centers and that I may have blood work and/or other medical tests, procedures and/or specialty consultations performed as part of my processing. I
understand that the results of the examination, tests, and consults will be reviewed and considered as part of my application file and are not performed as part of an individual healthcare treatment plan. The
MEPS/DoDMERB medical staff are not my healthcare providers. If I do not receive notice of an abnormal test or consult, I am not to assume that the results are normal. Furthermore, if any test or consult results
are abnormal, I am responsible for obtaining those results from the MEPS and for any necessary follow-up evaluations and/or treatment. If I am notified to return to the MEPS to discuss medical results, it is my
responsibility to take quick action to return to the MEPS to speak with the Chief Medical Officer (CMO). Any concerns that I have about my health and healthcare are my responsibility to address with my personal
healthcare provider(s).
l Understand that neither USMEPCOM or DoDMERB are financially responsible for costs associated with any necessary follow-up evaluations and/or treatment based on my screening evaluation. Any concerns that I
have about my health and healthcare are my responsibility to address with my personal healthcare provider(s)
l Understand that I must provide required documentation regarding my health history which, upon my accession, will become part of my Service member lifecycle medical treatment record.
l I agree that all personal information or data disclosed by myself or others on my behalf with my consent during this process may be further disseminated as needed during the accession process and that my
medical information is no longer protected by federal Health Insurance Portability and Accountability Act of 1966 (HIPAA) Privacy Regulations.
l Authorize release of records and information relating to grades, performance, individual education plans, and disciplinary proceedings. Under the Family Educational Rights and Privacy Act (FERPA) USMEPCOM/
DoDMERB is authorized to receive all my education/disciplinary records for evaluation of my acceptability for Service in the Armed Forces.
l Understand that I have the right to refuse to sign this authorization but also understand that failure to do so may cause me to be found disqualified for further processing.
l Understand this authorization will expire four years from the date of the signature below or sooner if written request is received by USMEPCOM/DoDMERB Staff Judge Advocate's Office. I have the right to revoke
this authorization in writing, except to the extent that the DoD has acted in reliance on this information.

1. APPLICANT
a. Signature

b. Date Signed (YYYYMMDD)

2. PARENT OR GUARDIAN SIGNATURE IS MANDATORY FOR MINOR APPLICANT, SIGNATURE IS OPTIONAL IF APPLICANT IS OF AGE
b. Signature

a. Name (Last, First, Middle Initial)

c. Date Signed (YYYYMMDD)

3. RECRUITING REPRESENTATIVE: (If a representative was used) I certify all information is complete and true to the best of my knowledge.
a. Name (Last, First, Middle Initial)

b. Recruiter Identification Number

c. Signature

d. Date Signed (YYYYMMDD)

SECTION III - MEDICAL HISTORY. Check each item "Yes" or "No". All "Yes" items must be fully explained in Section IV, Page 5.
CURRENTLY HAVE OR ANY HISTORY OF:
EYES
1. Double vision
2. Detached retina or surgery to repair a detached retina
3. Cataracts or surgery for cataracts

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YES

NO

CURRENTLY HAVE OR ANY HISTORY OF:

YES

NO

EYES (Continued)
4. Eye surgery to improve vision (RK, PRK, LASIK, etc.)
5. Night blindness
6. Glaucoma

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LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

SOCIAL SECURITY NUMBER (Last 4)

DoD ID NUMBER (If applicable)

SECTION III - MEDICAL HISTORY (Continued). Check each item "Yes" or "No". All "Yes" items must be fully explained in Section IV, Page 5.
CURRENTLY HAVE OR ANY HISTORY OF:

YES

NO

CURRENTLY HAVE OR ANY HISTORY OF:

7. Strabismus or "lazy eye" or any surgery to correct these

FEMALES ONLY:

8. Any other eye condition, injury or surgery

48. A change of menstrual pattern (other than pregnancy)

VISION

49. Pregnancy, abortion or miscarriage

9. Worn/wear contact lenses or glasses (Bring your contact lens
kit and solution so you can remove contacts during vision
testing, or for best results remove 72 hours prior. Bring your
eyeglasses no matter how old they are.)

51. Date of last PAP smear (YYYYMMDD)

10. Loss of vision in either eye

NO

50. Any abnormal PAP smear(s)

52. Diagnosed with endometriosis or ovarian cysts
53. Evaluation, treatment or surgery for any other gynecological
(female) disorder

11. Color vision deficiency or color blindness

54. Sexually transmitted disease (syphilis, gonorrhea, chlamydia,
genital warts, herpes, etc.)

EARS
12. Perforated ear drum or tubes in ear drum(s)

YES

N E E D DD 67
55. First day of last menstrual period (YYYYMMDD)

13. Ear surgery, to include mastoidectomy or repair of perforated
ear drum

56. Missing a testicle, testicular implant, or undescended testicle

14. Loss of balance or vertigo

57. Variocele, hydrocele, or any scrotal mass, swelling or pain

HEARING

58. Prostate problems

15. Hearing loss or wear a hearing aid
NOSE, SINUSES, MOUTH, AND LARYNX

59. Sexually transmitted disease (syphilis, gonorrhea, chlamydia,
genital warts, herpes, etc.)

16. Ear, nose, or throat trouble including tonsillectomy

URINARY SYSTEM

17. Chronic sinus infections or recurrent nose bleeds

60. Missing a kidney

18. Absence of, or disturbance of sense of smell

61. Kidney stone, infection or disease

19. Any surgery of your face, mandible or jaw

62. Kidney or urinary tract surgery of any kind

DENTAL
20. Do you wear dental braces or plan to wear braces? (If so,
your orthodontist must submit a letter stating that active
orthodontic treatment will be completed prior to active duty
date: release form/sample format can be found in the
Recruiter's Medical Guide.)

63. Blood or protein in urine
64. Painful or difficult urination
65. Bedwetting or treatment for bedwetting (previous 12 months)
66. Hernia

21. Tooth or gum problems (other than cavities)

SPINE AND SACROILIAC JOINTS

LUNGS, CHEST WALL, PLEURA, AND MEDIASTINUM

67. Back pain or back problem

22. Asthma
23. Wheezing
24. Shortness of breath
25. Bronchitis
26. Other breathing problems worsened by exercise, weather,
pollens, etc.
27. Used inhaler(s) or steroids for breathing problem(s)
28. Chronic cough or frequent coughing at night
29. Collapsed lung or other lung condition
30. History of chest, chest wall, or breast surgery
HEART
31. Heart murmur, valve problem or mitral valve prolapse
32. Palpitation, pounding heart or abnormal heartbeat

68. Herniated disk
69. Neck pain
70. Back or neck surgery
71. Abnormal curvature of your spine (any part)
UPPER EXTREMITIES
72. Painful shoulder, elbow, wrist, hand or fingers
73. Dislocated shoulder, elbow, wrist, hand or fingers
LOWER EXTREMITIES
74. Foot trouble (e.g., pain, corns, bunions, warts, ingrown toenails,
etc.)
75. Knee trouble (e.g., locking, giving out, or ligament injury, etc.)
76. Painful hip, knee, ankle, foot or toes
77. Dislocated hip, knee, ankle, foot or toes

33. Heart surgery
34. Pain or pressure in the chest
35. An abnormal electrocardiogram (EKG)
36. Any other heart problems

MISCELLANEOUS CONDITIONS OF THE EXTREMITIES
78. Bone, joint, or other orthopedic deformity
79. Loss of finger or toe, or extra finger or toe

37. Stomach, esophageal or intestinal ulcer

80. Loss of the ability to fully flex (bend) or fully extend a finger, toe,
or other joint
81. Impaired use of arms, hands, legs, or feet (any reason)

38. Difficulty swallowing

82. Arthritis, rheumatism, gout, or bursitis

39. Frequent indigestion or heartburn

83. Any swollen joint(s)

40. Gall bladder trouble or gallstones

84. Surgery on any joint/bone (including arthroscopy)

41. Jaundice (except neonatal) or hepatitis (liver disease)

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

42. Rupture/hernia

86. Pain or swelling at the site of an old fracture

ABDOMINAL ORGANS AND GASTROINTESTINAL SYSTEM

43. Surgery to remove or repair a portion of the intestine or
spleen (other than the appendix)
44. Chronic or recurrent intestinal problem of the small or large
bowel such as Irritable Bowel Syndrome, Crohn's disease,
Ulcerative Colitis, or Celiac disease
45. Rectal disease, hemorrhoids, or blood from the rectum

87. Any need to use corrective devices such as prosthetic devices,
knee brace(s), back support(s), lifts or orthotics
88. Any other orthopedic, muscle, or sports injury problems
VASCULAR
89. High or low blood pressure
90. Raynaud's phenomenon or disease

46. Hemorrhoid surgery
47. Bariatric surgery (weight loss surgery)

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91. Deep Vein Thrombosis (blood clot; leg or elsewhere)
92. Pulmonary embolism (blood clot in lung)

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LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

CURRENTLY HAVE OR ANY HISTORY OF:

SOCIAL SECURITY NUMBER (Last 4)

YES

SKIN AND CELLUAR

NO

DoD ID NUMBER (If applicable)

CURRENTLY HAVE OR ANY HISTORY OF:

YES NO

LEARNING, PSYCHIATRIC, AND BEHAVIORAL (Continued)

93. Acne

136. Been expelled or suspended from school

94. Atopic dermatitis or Eczema

137. Been kicked out or removed from your home

95. Psoriasis

138. Been arrested or other encounters with law enforcement

96. Large or painful scars

139. Been evaluated or treated, either with medication or counseling,
for a mental condition, depression or excessive worry

97. Any other skin problems
BLOOD AND BLOOD FORMING TISSUES

140. Nervous trouble of any sort (anxiety or panic attacks)

98. Anemia (iron deficiency, sickle cell, thalassemia)
141. Anorexia, bulimia, or other eating disorder

99. Blood clots requiring blood thinner medicine

142. Habitual stammering or stuttering

100. Absence or removal of the spleen

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101. Prolonged bleeding (after an injury or tooth extraction)

143. Have you ever purposely cut or harmed yourself

102. Any other blood or circulation problems

144. Have you ever attempted or considered suicide

SYSTEMIC

103. Adverse reaction to medication (describe reaction in Section IV)
104. Adverse reaction to serum, insect bites, or stings
105. Allergy to foods (milk, eggs, fish, meat, nuts, etc.)
106. Allergy to wool, latex, or other material
107. Tuberculosis or lived with someone who had tuberculosis
108. Positive test for tuberculosis (PPD or blood test)

145. Used illegal drugs or abused prescription drugs

146. Have you been evaluated, treated, or hospitalized for substance
abuse, addiction or dependence (including illegal drugs,
prescription medications or other substances)
147. Have you been evaluated, treated, or hospitalized for alcohol
abuse, dependence, or addiction
148. Post-traumatic Stress Disorder or excessive stress requiring
counseling and/or medication following a traumatic experience

109. Malaria
110. Disorder(s) of your immune system (including HIV)
111. Car, train, sea, or air sickness
ENDOCRINE AND METABOLIC
112. Thyroid trouble or goiter
113. High or low blood sugar
114. Diabetes or told that you should be tested for diabetes
NEUROLOGIC
115. Cerebrovascular incident (stroke)
116. Frequent or severe headaches, including migraines
117. Taking medication to prevent headaches
118. Lost time from work or school due to frequent or severe
headaches
119. A skull fracture
120. A head injury, memory loss, or amnesia
121. A period of unconsciousness or concussion

149. Any other learning, psychiatric, or behavioral problems
TUMORS AND MALIGNANCIES
150. Tumor, growth, cyst, or cancer of any type
MISCELLANEOUS
151. Cold injury, frostbite or cold intolerance
152. Heat injury, heat stroke or heat intolerance
SUPPLEMENTAL QUESTIONS
153. Are you taking any medications, to include over the counter
medications (OTCs), vitamin, herbal, or nutritional supplements
(If "yes", list all in Section IV.)
154. Any recent unexplained gain or loss of weight
155. Artificial or replacement body part (eye, bone, palate, hip, knee,
joint, leg, arm, etc.)
156. Have you ever had any illness or injury other than those already
noted? (If "yes", specify when, where and give details in
Section IV.)

122. Loss of memory or amnesia, or neurological symptoms
123. Paralysis
124. Meningitis, encephalitis, or other neurological problems
125. Seizures, convulsions, epilepsy or fits
126. Dizziness or fainting spells
127. Any other neurologic problems
SLEEP DISORDERS
128. Sleepwalking or narcolepsy
129. Frequent trouble sleeping
130. Sleep apnea or severe snoring
LEARNING, PSYCHIATRIC, AND BEHAVIORAL
131. Evaluated or treated for Attention Deficit Disorder (ADD) or
Attention Deficit Hyperactivity Disorder (ADHD)
132. Taken (or taking) medication, drugs, or any substance to
improve attention, behavior, or physical performance

157. Have you ever been treated in an Emergency Room? (If "yes",
explain in Section IV.)
158. Have you ever been a patient in any type of hospital (including
being kept overnight)? (If "yes", specify when, where, why, and
name of doctor and complete address of hospital in Section IV.)
159. Have you ever had, or have you been advised to have any
operations or surgery? (If "yes", describe and give age at which
occurred in Section IV.)
160. Have you ever been rejected for military Service for any
reason? (If "yes", give date and reason in Section IV.)
161. Have you ever been discharged from the military Service for
any reason? (If "yes", give date, reason, and type of discharge,
whether honorable, other than honorable, for unfitness or
unsuitability in Section IV.)
162. Have you ever been refused employment or been unable to
hold a job or stay in school because of any of the following:
(If "yes", answer a - d below and give reasons in Section IV.)
a. Sensitivity to chemicals, dust, sunlight, etc.

133. Diagnosed with a learning disorder, to include dyslexia
134. Received counseling of any type

b. Inability to perform certain motions
c. Inability to stand, sit, kneel, lie down, etc.

135. Seen a psychiatrist, psychologist, social worker, counselor or
other professional for any reason (inpatient or out-patient)
including counseling or treatment for school, adjustment, family,
marriage, divorce, depression, anxiety, or treatment of alcohol,
drug or substance abuse (Applicant or recruiter will request
sealed medical supporting documents from health care providers marked "CONFIDENTIAL: MEPS MEDICAL DEPARTMENT" and submit directly to MEPS medical personnel.)

DD FORM 2807-2, 20180409 DRAFT

d. Other medical reasons
163. Applied for and/or received disability evaluation and/or
compensation for an injury or other medical conditions
(If "yes", provide details in Section IV.)
164. Have you ever been denied life insurance? (If "yes", provide
reason(s) in Section IV.)

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LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

SOCIAL SECURITY NUMBER (Last 4)

DoD ID NUMBER (If applicable)

SECTION IV - APPLICANT COMMENTS. Explain all "Yes" answers to questions 1 - 164 above.
Begin with the Item Number. Describe answer(s) fully: provide date(s) of problem(s)/condition(s); provide names of Health Care Providers (HCPs),
Clinic(s) and/or Hospital(s) along with the City and State; explain what was done (e.g., evaluation and/or treatment); and describe your current medical
status. Attach additional sheet(s) if necessary and sign and date each additional page. Obtain and attach copies of applicable medical evaluation and
treatment records.

N E E D DD 67

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LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

SOCIAL SECURITY NUMBER (Last 4)

DoD ID NUMBER (If applicable)

SECTION V - HEALTH CARE PROVIDER/INSURANCE CARRIER CONTACT INFORMATION:
Current Primary Care Physician(s)/Practitioner(s) and/or Clinic(s) where care is received and Current/Previous Insurance Carrier(s) information.
Attach additional sheets if necessary.
1. CURRENT PRIMARY CARE PHYSICIAN(S)/PRACTITIONER(S) AND/OR CLINIC(S)
a. NAME(S)

b. ADDRESS (Include ZIP Code)

c. TELEPHONE (Include Area Code)

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2. PREVIOUS PRIMARY CARE PHYSICIAN(S)/PRACTITIONER(S) AND/OR CLINIC(S)
a. NAME(S)

b. ADDRESS (Include ZIP Code)

c. TELEPHONE (Include Area Code)

3. CURRENT INSURANCE AND/OR PHARMACY BENEFIT MANAGER(S)
a. NAME(S)

b. ADDRESS (Include ZIP Code)

c. TELEPHONE (Include Area Code)

4. PREVIOUS INSURANCE AND/OR PHARMACY BENEFIT MANAGER(S)
a. NAME(S)

b. ADDRESS (Include ZIP Code)

c. TELEPHONE (Include Area Code)

5. ADDITIONAL ISSURANCE AND/OR PHARMACY BENIFIT MANAGER(S)
a. NAME(S)

DD FORM 2807-2, 20180409 DRAFT

b. ADDRESS (Include ZIP Code)

c. TELEPHONE (Include Area Code)

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LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

SOCIAL SECURITY NUMBER (Last 4)

DoD ID NUMBER (If applicable)

SECTION VI - MEDICAL RECORDS RELEASE
Applicant (Patient) Name:

Date of Birth (MM/DD/YYYY)

Social Security Number:

Address:

Phone:

1. I authorize the release of the following information by ALL holders of my medical records/information (check all applicable) Choosing not to release all records
will delay medical qualification determination.

All records

N E E D DD 67
Abstract

Inpatient medical records

Laboratory/pathology records

X-ray films/radiology records

Billing records

Pharmacy/prescription records

Psychotherapy/psychiatic care records

HIV, drug, and/or alcohol use records

Other

Outpatient medical records

Describe specifically:

2. Please send my records listed above to:
Name:

Address:

Phone:

Fax:

3. I authorize the release of the medical records that I marked above through an electronic health exchange if available.
4. I understand that if the person or agency that receives my information is not a health care provider or health plan covered by the HIPAA privacy
regulations, the information described above may be redisclosed and is no longer protected by these regulations.
5. This authorization for medical records release will expire no later than 2 years from the date of signature or as directed by local laws. I understand
written notification is necessary to cancel this authorization before such date and can be addressed to the department listed at item 2 of this form. I
am aware that my cancellation will not be effective as to disclosures already made in reference to this authorization.
6. I understand that this disclosure may include information regarding drug abuse, alcoholism, or alcohol abuse, psychiatric or mental illness,
Acquired Immunodeficiency Syndrome (AIDS) or infection with HIV regulated by Federal Statute (42 CFR Part 2).

7. Applicant
a. Signature

b. Date Signed (YYYYMMDD)

8. Parent or Guardian Signature is mandatory for minor applicant, signature is optional if applicant is of age
a. NAME (Last, First, Middle Initial)

DD FORM 2807-2, 20180409 DRAFT

b. Signature

c. Date Signed (YYYYMMDD)

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LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

SOCIAL SECURITY NUMBER (Last 4)

DoD ID NUMBER (If applicable)

SECTION VII - MEDICAL PROVIDER'S SUMMARY AND DESCRIPTION OF PERTINENT INFORMATION:
Review and comment on all medical records, electronically provided medical history information, and other electronic data available in the Department of Defense
Accessions Processing System. Medical providers may also develop any additional medical history deemed important and record significant findings here or by
interview and document them on DD Form 2808, "Report of Medical Examination". Attach additional sheet(s) if necessary.
COMMENTS:

N E E D DD 67

DD FORM 2807-2, 20180409 DRAFT

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LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

DoD ID NUMBER (If applicable)

SOCIAL SECURITY NUMBER (Last 4)

SECTION VIII - MEDICAL PROVIDER'S PRESCREEN DETERMINATION BASED ON AVAILABLE INFORMATION:
1.a. DATE
(YYYYMMDD)

b. MEDICAL PROCESSING STATUS
PA

PRW

PH

RJ

METR

c. IF NOT WITHIN STANDARDS:
PNJ

ICD

CONDITION

PULHES

SMWRA INPUT

d. PROVIDER
INITIALS

N E E D DD 67
KEY: PA = Processing Authorized; PRW = Processing Requested by SMWRA; PH = Processing Hold; RJ = Return Justified; METR = Medical Evaluation and/or
Treatment Records; PNJ = Processing Not Justified; ICD = International Classification of Disease Code; PULHES = P (Physical Capacity), U (Upper Extremities),
L (Lower Extremities), H (Hearing), E (Eyes), S (Psychiatric); SMWRA = Service Medical Waiver Review Authority.
2. *FOR MEPS USE ONLY:
ON EXAM:

a. PSN COMP

b. PSN INCOM

c. NPS

d. *AE

e. *RE

f. *ME

g. *OE

h. DATE
(YYYYMMDD)

i. PROVIDER
INITIALS

3. AUTHORIZING MEDICAL PROVIDER
b. SIGNATURE

a. NAME (Last, First, Middle Initial)

c. DATE SIGNED (YYYYMMDD)

4. EXAMINING PROVIDER
a. NAME (Last, First, Middle Initial)

DD FORM 2807-2, 20180409 DRAFT

b. SIGNATURE

c. DATE SIGNED
(YYYYMMDD)

5. NUMBER OF ADDITIONAL SHEETS
SUBMITTED

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