Report of Medical History/Examination

OMB 0990-0324

Health professionals applying to the Corps will be required to complete form PHS-7060. The self-reported medical history form requires 'yes' or 'no' answers. 'Yes' answers will trigger additional questionnaires (PHS-7053-Allergies; PHS-7054 Head Injury; PHS-7055-Injury; PHS-7056-Headache; PHS-7057-Gyn; PHS-7061-Oswesty Low Back). The Medical Evaluation Officer will use the form to determine medical suitability for the Corps.

The latest form for Report of Medical History/Examination expires 2023-09-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form PHS-6355 Report of Dental Examination Form
Form PHS-7061 Qwestry Low Back Questionnaire Form
Form PHS-7057 GYN Questionnaire Form
Form PHS-7056 Headache Questionnaire Form
Form PHS-7055 Injury Questionnaire Form
Form PHS-7054 Head Injury Questionnaire Form
Form PHS-7053 Allergies Questionnaire Form
Form PHS-6379 Report of Medical Examination Form
30-day FRN 0990-0324.pdf Supplementary Document
0990-0324Supporting Statement 07-2020.docx Supporting Statement A
Report of Dental Examination Form
Qwestry Low Back Questionnaire Form
GYN Questionnaire Form
Headache Questionnaire Form
Injury Questionnaire Form
Head Injury Questionnaire Form
Allergies Questionnaire Form
Report of Medical Examination Form

All Historical Document Collections

202006-0990-002 Approved without change	Revision of a currently approved collection	2020-07-27
201612-0990-001 Approved without change	Reinstatement without change of a previously approved collection	2017-03-13
200710-0990-001 Approved without change	New collection (Request for a new OMB Control Number)	2007-10-17

OMB Details

Report of Medical Examination

Federal Enterprise Architecture: General Government - Central Records & Statistical Mgt

Form PHS-6379

Medical History Record

Fillable Fileable

Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.