Dd Form 2492 - Dod Medical Examination Review Board (Dodmerb) Report Of Medical History Page 3

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DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)
Form Approved
REPORT OF MEDICAL EXAMINATION
OMB No. 0704-0396
Expires Aug 31, 2003
(Please read Privacy Act Statement before completing this form.)
The public reporting burden for this collection of information is estimated to average 15 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 Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports
(0704-0396), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. 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. RETURN COMPLETED FORM TO DODMERB/DR, 8034 EDGERTON
DRIVE, SUITE 132, USAF ACADEMY CO 80840-2200.
DODMERB USE ONLY
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 Account Number (SSN) is
used for positive identification of records.
APPLICANT DATA
1. DATE OF EXAMINATION (YYYYMMDD)
2. NAME (Last, First, Middle Initial)
3. SOCIAL SECURITY ACCOUNT NUMBER
4. DATE OF BIRTH (YYYYMMDD)
5. AGE
6. SEX
7. RACE (Ethnic Group)
8. MAILING ADDRESS OR DET NUMBER/BTN NUMBER
10. EXAMINER ADDRESS (Street, City, State and Zip Code)
9. STATUS (X one)
ACTIVE DUTY
CIVILIAN
RESERVE/GUARD
MEASUREMENTS
14 PULSE
12. WEIGHT (to nearest pound)
11. HEIGHT (to nearest 1/4 inch)
13. BLOOD PRESSURE
15. EKG
SYSTOLIC
/
DIASTOLIC
STANDING
SITTING
NORMAL
ABNORMAL
16. AUDIOMETER
17. READING ALOUD TEST
500
1000
2000
3000
4000
6000
500
1000
2000
3000
4000
6000
SATISFACTORY
UNSATISFACTORY
RIGHT
LEFT
(Explain in Item 59)
18. DISTANT VISION
MANIFEST
CYCLO
BY LENS
20. NEAR VISION
19. REFRACTION
RIGHT 20/
CORR TO 20/
SPH
CYL
AXIS
20/
CORR TO 20/
BY
LEFT 20/
CORR TO 20/
SPH
CYL
AXIS
20/
CORR TO 20/
BY
23. COLOR VISION
24. DEPTH PERCEPTION
21. HETEROPHORIA/TROPIA
22. COVER TEST
(Far only)
TEST USED
SCORE
TEST USED
RESULTS
ESO
EXO
RH
LH
PIP
VTA-ND/OVT/AFVT
No. Passed
No. Failed
PASS
(Non-Tropia)
No. Passed
No. Failed
DPA-V
FALANT
OTHER (Specify)
TITMUS/STEREO FLY
FAIL (Tropia)
(Arcs per second)
25. NEAR POINT OF CONVERGENCE
26. OCULAR MOTILITY AND BINOCULARITY (RED LENS TEST)
PASS
FAIL
IF FAILED:
DIPLOPIA
SUPPRESSION
LABORATORY
27. URINALYSIS
PROTEIN
NEG
T
1+
2+
3+
4+
MICROSCOPIC EXAMINATION (If required) (X one)
SUGAR
NEG
T
1+
2+
3+
4+
NEGATIVE
BLOOD
NEG
T
1+
2+
3+
4+
POSITIVE
LEUKOCYTE
(List results)
NEG
T
1+
2+
3+
4+
ESTERASE
29. OTHER TESTS (Specify type and results)
28. BLOOD
TYPE
RH FACTOR
HEMATOCRIT
HEMOGLOBIN
DD FORM 2351, SEP 2000
PREVIOUS EDITION IS OBSOLETE.
DoD Exception to SF 88 Approved by GSA/OIRM 4-88

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