DATE (YYYYMMDD)
DATE (YYYYMMDD)
5. In the past five (5) years, have any members of your family, excluding service member, been treated for, or had any problems related to any
of the following? (You will have an opportunity to discuss all "YES" answers with a screener.)
YES NO
NAME
PAGE 2, DA FORM 7246, JUN 2009
PRESCRIBED MEDICATION
Problems with sight (other than corrected by
glasses)
YES NO YES NO
Problems with hearing
Heart condition
Loss of mobility (requiring use of a wheelchair/
walker or aid in mobility)
Cerebral Palsy
Delayed Speech
Sickle Cell Trait/Disease
Cancer
High blood pressure
Other, if yes, explainDiabetes
Seizure disorder
MENTAL HEALTH:
6. In the past five (5) years, have any members of your family, excluding service member, been treated for, or had any problems related to any
of the following? (You will have an opportunity to discuss all "YES" answers with a screener.)
Depression
Suicidal thoughts/ideas, gestures, attempts
YES NO YES NO
Alcohol and drug use or abuse
Emotional problems
Behavioral problems/acting out behavior
Received therapy (marital, family, individual or
group counseling)
7. Have any members of your family, excluding service member, been in any of the following? Inpatient Psychiatric Facility,
Residential Treatment Center, Group Homes, Day Treatment Centers, Drug and Alcohol Treatment Rehabilitation Center. If
Yes, please explain:
YES NO
EDUCATION
8. Do any of your children now have, or have they ever had, any of the following?
YES NO YES NO
Slow development (infants and preschoolers)
Intellectual disability
Learning problems (school)
Special services (i.e., OT, PT, Speech, etc.)
for special education
9. Are any of your children receiving Special Education help in school (not in regular class placement and on an Individual
Education Plan (IEP))? If yes, who?
YES NO
Commanders will take appropriate action against soldiers who knowingly provide false information, or who knowingly fail or refuse to enroll
family members that meet the criteria for enrollment. (A false official statement is a violation of Article 107, Uniform Code of Military Justice
(UCMJ).) These actions will include, at a minimum, a general officer letter of reprimand.
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APD AEM v1.01ES
4. Are any family members, excluding service member, taking any prescribed medication other than birth control pills on a
regular basis?
Asthma, allergies or other respiratory problems
Referral to, diagnosed by, or therapy with a
Psychiatrist, Psychologist, or Social Worker
in reference to a mental health problem
Counseling services for school-related problems
According to AR 608-75, Exceptional Family Member Program, soldiers will provide accurate information as required when requested to do so
by Army officials. Knowingly providing false information in this regard may be the basis for disciplinary or administrative action. For soldiers,
refusal to provide information may preclude successful processing of an application for family travel or command sponsorship.
All the above information is true and correct to the best of my knowledge. I understand that it is my responsibility to provide any information
about changes in medical or educational status for all members of my family, after the date indicated below, and prior to PCS move.
PRINTED NAME OF MILITARY SPONSOR OR
SPOUSE COMPLETING THIS FORM
PRINTED NAME OF PHYSICIAN OR MEDICAL
PRACTITIONER IF UNDER THE SUPERVISION OF A
PHYSICIAN
SIGNATURE OF PHYSICIAN OR MEDICAL
PRACTITIONER IF UNDER THE SUPERVISION OF A
PHYSICIAN
SIGNATURE OF MILITARY SPONSOR OR SPOUSE
COMPLETING THIS FORM
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