DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)
REPORT OF MEDICAL EXAMINATION
(Please read Privacy Act Statement before completing this form.)
Form Approved
OMB No. 0704-0396
Expires Sep 30, 2006
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO DODMERB/DR, 8034 EDGERTON
DRIVE, SUITE 132, USAF ACADEMY CO 80840-2200.
1. DATE OF EXAMINATION (YYYYMMDD) 2. NAME (Last, First, Middle Initial) 3. SOCIAL SECURITY ACCOUNT NUMBER
APPLICANT DATA
4. DATE OF BIRTH (YYYYMMDD) 5. AGE 6. SEX 7. RACE (Ethnic Group)
a. APPLICANT MAILING ADDRESS (Include ZIP Code)
9. STATUS (X one)
10. EXAMINER ADDRESS (Street, City, State and Zip Code)
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.
MEASUREMENTS
11. HEIGHT (to nearest
1/4 inch)
STANDING SITTING
12. BLOOD PRESSURE
13. AUDIOMETER
500 1000 2000 3000 4000 6000
14. READING ALOUD
TEST
SATISFACTORY
UNSATISFACTORY
(Explain in Item 57)
16. WEIGHT (to
nearest pound)
15. PULSE
17. DISTANT VISION
RIGHT 20/
LEFT 20/
CORR TO 20/
CORR TO 20/
18. REFRACTION
SPH
SPH
CYL
CYL
CYCLO
MANIFEST BY LENS
AXIS
AXIS
19. NEAR VISION
20/
20/
CORR TO 20/
CORR TO 20/
BY
BY
20. HETEROPHORIA/TROPIA
(Far only)
ESO EXO RH LH
21. COVER TEST
PASS
(Non-Tropia)
FAIL (Tropia)
22. COLOR VISION
PIP
FALANT
TEST USED
OTHER (Specify)
RESULTS
No. Passed No. Failed
23. DEPTH PERCEPTION
VTA-ND/OVT/AFVT
DPA-V
TITMUS/STEREO FLY
TEST USED SCORE
24. NEAR POINT OF CONVERGENCE
25. VIVID RED/GREEN (If fail Item 22)
PASS FAIL DIPLOPIA SUPPRESSION
LABORATORY
27. URINALYSIS
PROTEIN
SUGAR
BLOOD
LEUKOCYTE
ESTERASE
NEG
NEG
NEG
NEG
T
T
T
T
1+
1+
1+
1+
2+
2+
2+
2+
3+
3+
3+
3+
4+
4+
4+
4+
NEGATIVE
MICROSCOPIC EXAMINATION (If required) (X one)
POSITIVE
(List results)
28. OTHER TESTS (Specify type and results)
DD FORM 2351, MAR 2004
PREVIOUS EDITION IS OBSOLETE.
DoD Exception to SF 88 Approved by GSA/OIRM 4-88
DODMERB USE ONLY
No. Passed No. Failed
(Arcs per second)
/
SYSTOLIC DIASTOLIC
RIGHT LEFT
500 1000 2000 3000 4000 6000
8. ADDRESS INFORMATION (If left blank will delay processing)
b. ROTC DETACHMENT CODE (If applicable):
26. OCULAR MOTILITY AND BINOCULARITY (RED LENS TEST)
IF FAILED:PASS FAIL
ACTIVE DUTY CIVILIAN RESERVE/GUARD
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 the Department of Defense, Executive Services and Communications Directorate (0704-0396). 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.
