Dd Form 2492 - Dod Medical Examination Review Board (Dodmerb) Report Of Medical History Page 9

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PHYSICAL EXAM ROUTING SHEET
NAME:
RANK/UNIT:
L4SSN:
LOCATION;
TODAY’S DATE:
1
FLOOR
_________
ST
JULIE HILL (CHCS/DMIS INPUT)
3
FLOOR
DENTAL: ____________________________
RD
BASEMENT
LAB: _________________________________
BASEMENT
X-RAY:______________________________
BASEMENT
INTERNAL MONITORING __________
1
FLOOR
AUDIO:_______________________________
ST
1
FLOOR
OPT:__________________________________
ST
1
FLOOR
VITAL SIGNS_________________________
ST
1
FLOOR
EKG: _________________________________
ST
PREV MED____________________________
_________________________
TYPE OF PHYSICAL ______________________
PART II DATE/TIME ______________________
PROVIDER ________________________________
NOTES: ____________________________________

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