DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)
REPORT OF MEDICAL HISTORY
(This information is for official and medically confidential use only and will not be released to unauthorized persons.)
SECTION I
Mark each item "Yes" or "No". Every question must be answered. Every "Yes" must be explained in the REMARKS section. Mark and
explain each item to the best of your ability. Be perfectly honest! Your medical records may be requested to clarify your medical history.
7. HAVE YOU EVER OR DO
YOU NOW USE ANY OF
THE FOLLOWING:
YES NO
YES NO
Amphetamines
Barbiturates
Cocaine
Narcotic Drugs
HAVE YOU EVER HAD OR DO YOU NOW HAVE:
DoD Exception to SF93 approved by GSA/IRMS (8-91)
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.
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 Number (SSN) is used for positive identification of records.
1. NAME (Last, First, Middle Initial) 2. SOCIAL SECURITY NUMBER 3. TELEPHONE NO. (Include area code)
4. PURPOSE OF EXAMINATION 5. EXAMINATION FACILITY OR EXAMINER AND ADDRESS (Include ZIP Code) 6. DATE OF EXAMINATION
(YYYYMMDD)
DO YOUYES NO
Chemical Inhalants
Hallucinogens
Marijuana
9. Wear contact lenses or
corneal eye retainers
(If Yes, complete 9a.)
10. HAVE YOU EVER HAD YOUR VISION IMPROVED BY METHODS OTHER THAN STATED IN
QUESTIONS 8 OR 9?
8. Wear glasses
9a. If you wear contact lenses, how many days have they
been removed prior to this examination?
Less than 3
Type lens:
3 - 20
Hard
21 or over
Soft
YES NO
11. Eye trouble (exclude glasses, contact lenses)
12. Have fluctuating vision or double vision
13. Have any allergies
14. Take any medications regularly
15. Stutter or stammer
16. Frequent, severe, or migraine headaches
17. Fainting or dizzy spells
18. Periods of unconsciousness
19. Head injury or skull fracture
20. Epilepsy, seizures or convulsions
21. Loss of memory (amnesia)
22. Depression, anxiety, excessive worry, or
40. Gallbladder trouble or gallstones
41. Hepatitis (yellow jaundice)
42. Hemorrhoids or rectal disease
43. Black or bloody stools
44. Frequent or painful urination
45. Bed wetting after age 12
46. Blood, protein, or sugar in urine
47. History of diabetes
48. Kidney stone
49. Hernia or rupture
50. Any bone or joint problem, injuries, surgery
66. Sleepwalking episodes after age 12
67. Easily fatigued
68. Motion sickness (car, train, sea, or air)
69. X-ray or other radiation therapy
70. Sensitivity to chemicals, dust, sunlight, etc.
71. Learning disabilities or speech problems
YES NO YES NO
nervousness
23. Any mental condition or illness
24. Frequent trouble sleeping
25. Hearing loss
26. Ear, nose, or throat trouble
27. Sinusitis or sinus trouble
28. Hay fever or allergic rhinitis
29. Tooth/gum trouble, or current orthodontics
30. Thyroid trouble
31. Chronic cough or lung disease
32. Asthma or wheezing
33. Unusual shortness of breath
34. Pain or pressure in chest
35. Palpitation or pounding heart
36. Heart trouble or heart murmur
37. High blood pressure
38. Coughed up or vomited blood
39. Stomach, liver, or intestinal trouble
or medical treatment
51. Steel pins, plates, or staples in any bones
52. Wear a bone or joint brace or support
53. Back pain or trouble
54. Paralysis or weakness
55. Foot trouble/use orthotics
56. Rheumatic fever
57. Tuberculosis or positive TB test
58. Sexually transmitted disease (syphilis,
gonorrhea, herpes)
59. Skin conditions such as acne, psoriasis,
hand or foot rashes, eczema, or dry skin
60. Adverse reaction to vaccines, drugs,
medicines, foods, insect bites or stings
61. Eating disorder
62. Recent gain or loss of weight
63. Excessive bleeding or easy bruising
64. Tumor, growth, cyst, or cancer
65. Considered or attempted suicide
YES NO
HAVE YOU EVER
72. Been refused employment or been unable to
hold a job or stay in school because of:
a. Inability to perform certain movements?
b. Inability to assume certain positions?
c. Other medical reasons?
73. Been rejected for or discharged from military
service because of physical, mental or other
reasons?
74. Been denied or rated up for life insurance?
75. Received or applied for pension or
compensation for existing disability?
76. Had or been advised to have, any surgical
operations?
77. Consulted, or been treated by clinics,
hospitals, physicians, healers, or other
practitioners for other than minor illnesses?
78. Had any injury or illness other than those
already noted?
YES NO
FEMALES ONLY (Complete Items 79 - 82)
79. Been treated for a female disorder, painful
periods, or cramps
80. Had a change in menstrual pattern
81. Are you now pregnant?
82. Date of last menstrual period (YYYYMMDD)
DD FORM 2492, MAR 2004
PREVIOUS EDITION IS OBSOLETE.
Alcohol (Amount,
frequency, treatment,
if any)
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.
