Fillable INSTRUCTIONS FOR DD FORM 2807-2, MEDICAL PRESCREEN OF (New York State)

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INSTRUCTIONS FOR DD FORM 2807-2, MEDICAL PRESCREEN OF (New York State)

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INSTRUCTIONS FOR DD FORM 2807-2,
MEDICAL PRESCREEN OF MEDICAL HISTORY REPORT
1. This form is to be completed by each individual who requires medical processing in accordance with Army Regulation 40-501
Chapter 2 standards, or Department of Defense Directive 6130.3, "Physical Standards for Appointment, enlistment, or Induction."
The form should be completed by the applicant with the assistance of the recruiter, parent(s), or guardian, as needed (see page 2).
2. This form replaces the existing medical prescreening form (DD Form 2246). The revisions are designed to ensure that medical
prescreening questions "used by recruiters and by U.S. Military Entrance Processing Command are specific, unambiguous and tied
directly to the types of medical separations most common for recruits during basic training and follow-on training" (per P.L. 105-85,
Div. A, Title V, S 532).
3. Use of this form will also facilitate efficient, timely, and accurate medical processing of individuals applying for service in the
United States Armed Forces or Coast Guard. The form is designed to assist recruiters in the medical pre-screening of applicants.
4. The individual completing the DD Form 2807-2 will submit the form, at a minimum, 1 processing day in advance to the MEPS
projected to process the individual. A minimum of 2 processing days in advance is required if support documentation (e.g., private
physicians paperwork, treatment records, etc.) is required to augment the MEPS CMO review.
EXPLANATION OF CODES.
Items are followed by numbers that refer to the following:
(1) If the applicant has been seen by a physician and/or has been hospitalized for the condition, obtain medical documentation with
a medical release form and submit records to the MEPS Medical Section. After the MEPS Medical Officer reviews the provided
information, the appropriate recruiting service member will be informed of the examinee's processing status, or if additional record
review or specialty consultation may be required for further processing or qualification determination.
a. If the applicant was evaluated and/or treated on an out-patient basis, obtain a copy of actual treatment records of the private
medical doctor (PMD) or health care provider (HCP), to include (if any):
- office or clinic assessment and progress notes, including the initial assessment documents, subsequent evaluation and
treatment documents, and record and date when released from doctor's care to full, unrestricted activity;
- emergency room (ER) report;
- study reports (e.g., x-ray report(s), magnetic resonance imaging (MRI) report(s), or Computerized Tomography (CT) scan
report(s), etc.);
- procedure reports (e.g., arthroscopy, electroencephalogram (EEG; brain wave test), echocardiogram (ultrasound of the heart),
etc.);
- pathology reports (e.g., if tissue specimens taken from the body and sent to lab for microscopic diagnosis, etc.);
- specialty consultation records (e.g., neurologist, cardiologist, OB/Gynecologist, gastroenterologist, orthopedic surgeon,
pulmonologist, allergist, etc.).
b. If the applicant was hospitalized, then obtain a copy of the hospital record, to include (if any): ER report, admission history and
physical, study reports, procedure reports, operative report (especially necessary for surgery to bone or joint), pathology report,
specialty consultation reports, and discharge summary.
(2) If an applicant has been diagnosed or treated since age 12 for any attention disorder (Attention Deficit Disorder (ADD) or
Attention Deficit Hyperactivity Disorder (ADHD), etc.), academic skills or perceptual defect, or has had an Individual Education Plan
(IEP), call the MEPS for additional instructions.
(3) Condition to be discussed with the examining Medical Officer at time of the medical examination.
(4) Call MEPS Medical Section to discuss examinee's medical history BEFORE sending the individual in for physical examination.
(5) Send medical reports to MEPS for review before sending applicant for physical ("papers only" medical review), and MEPS
Medical Section will advise regarding further medical processing. Records pertaining to non-psychiatric diagnoses may be sent to
the Medical Section of the processing MEPS, with the envelope stating: "CONFIDENTIAL: MEPS MEDICAL SECTION."
(6) Send all documentation relating to ANY past or present evaluation, treatment or consultation with a psychiatrist, psychologist,
counselor or therapist, on an inpatient or out-patient basis for any reason, including but not limited to counseling or treatment for
adjustment or mood disorder, family or marriage problem, depression, treatment or rehabilitation for alcohol, drug or other
substance abuse, directly from the treating clinician and/or hospital to the MEPS Chief Medical Officer. The envelope must bear the
following statement: "CONFIDENTIAL: FOR EYES OF THE MEDICAL OFFICER ONLY."
(7) May require an orthopedic consult, scheduling to be coordinated by the MEPS CMO and Medical Section.
DD FORM 2807-2, OCT 2003
Page 1 of 6 Pages
DD FORM 2807-2, OCT 2003
Page 2 of 6 Pages
WARNING: The information you have given constitutes an official statement. Federal law provides severe penalties (up to 5 years confine-
ment or a $10,000 fine or both), to anyone making a false statement. If you are selected for enlistment, commission, or entrance into a
commissioning program based on a false statement, you can be tried by military courts-martial or meet an administrative board for discharge
and could receive a less than honorable discharge that would affect your future.
a. HAVE YOU EVER HAD OR DO YOU NOW HAVE: YES NO YES NO
2. Mark each item "YES" or "NO". Every item marked "YES" must be fully explained in Item 2b.
(1) Asthma, wheezing, or inhaler use (4)
(2) Dislocated joint, including knee, hip, shoulder, elbow, ankle
or other joint (1)(7)
(3) Epilepsy, fits, seizures, or convulsions (4)
(4) Sleepwalking (4)
(5) Recurrent neck or back pain (4)(1)(7)
(6) Rheumatic fever (4)
(7) Foot pain (3)
(8) A swollen, painful, or dislocated joint or fluid in a joint
(knee, shoulder, wrist, elbow, etc.) (1)(7)
(9) Double vision (4)
(10) Periods of unconsciousness (4)
(11) Frequent or severe headaches causing loss of time from
work or school or taking medication to prevent frequent or
severe headaches (4)
(12) Wear contact lenses (If so, bring your contact lens
kit and solution so you can remove your contact when we
test your vision at the MEPS; also, if you have a pair of
eyeglasses, bring them with you no matter how old they are.)
(13) Fainting spells or passing out (4)
(14) Head injury, including skull fracture, resulting in concussion,
loss of consciousness, headaches, etc. (4)
(15) Back surgery (4)
(16) Seen a psychiatrist, psychologist, social worker, counselor or
other professional for any reason (inpatient or outpatient)
including counseling or treatment for school, adjustment,
family, marriage or any other problem, to include depression,
or treatment for alcohol, drug or substance abuse (6)(2)
(17) Any of the following skin diseases:
(a) Eczema (5)
(b) Psoriasis (5)
(c) Atopic dermatitis (5)
(18) Irregular heartbeat, including abnormally rapid or slow
heart rates (4)
(19) Allergic to bee, wasp, or other insect stings
(itching/swelling all over and/or get short of breath) (4)
(20) Heart murmur, valve problem or mitral valve prolapse (4)
(21) Allergic to wool (4)
(22) Heart surgery (4)
(23) Been rejected for military service (temporary
or permanent) for medical or other reasons (4)
(24) Any other heart problems (4)
(25) High blood pressure (4)
(26) Discharged from military service for medical reasons (4)
(27) Ulcer (stomach, duodenum or other part of intestine) (4)
(28) Received disability compensation for an injury or other medical
condition (4)
(29) Hepatitis (liver infection or inflammation) (4)
(30) Intestinal obstruction (locked bowels), or any other chronic or
recurrent intestinal problem, including small intestine or colon
problems, such as Crohn's disease or colitis (4)
(31) Detached retina or surgery for a detached retina (4)
(32) Surgery to remove a portion of the intestine (other than the
appendix) (4)
(33) Any other eye condition, injury or surgery (4)
(34) Are you over 40? (If so, call the MEPS for information on
special requirements for over-40 physicals) (4)
(35) Gall bladder trouble or gall stones (4)
(36) Jaundice (4)
(37) Missing a kidney (4)
(38) Allergy to common food (milk, bread, eggs, meat, fish or
other common food) (4)
(40) (Males only) Missing a testicle, testicular implant, or
undescended testicle (4)
(41) Broken bone requiring surgery to repair (with or without pins,
plates, screws or other metal fixation devices used in repair)
(42) Ruptured or bulging disk in your back or surgery
for a ruptured or bulging disk (4)
(43) Thyroid condition or take medication for your thyroid (4)
(44) Limitation of motion of any joint, including knee, shoulder,
wrist, elbow, hip or other joint (4)(1)(7)
(45) Drug or alcohol rehab (4)
(46) Kidney, urinary tract or bladder problems, surgery, stones or
other urinary tract problems (4)
(47) Sugar, protein or blood in urine (4)
(48) Surgery on a bone or joint (knee, shoulder, elbow, wrist, etc.)
including Arthroscopy with normal findings (1)(7)
(49) Taking any medications (If so, list reason in Item 2b.)
OMB No. 0704-0413
OMB approval expires
Oct 31, 2006
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM AS INDICATED ON PAGE 2.
PRIVACY ACT STATEMENT
AUTHORITY: 10 USC 504, 505, 507, 532, 978, 1201, 1202, and 4346; and E.O. 9397 (SSAN).
PRINCIPAL PURPOSE(S): To obtain medical data for determination of medical fitness for enlistment, induction, appointment and retention for applicants and
members of the Armed Forces. The information will also be used for medical boards and separation of Service members from the Armed Forces.
ROUTINE USE(S): None.
DISCLOSURE: Voluntary; however, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application to
enter the Armed Forces. For an Armed Forces member, failure to provide the information may result in the individual being placed in a non-deployable status.
a. LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX) c. SOCIAL SECURITY NUMBER b. DATE OF BIRTH (YYYYMMDD)
1. APPLICANT
MEDICAL PRESCREEN OF MEDICAL HISTORY REPORT
(Chapter #2 Physicals Only)
e. WEIGHTd. HEIGHT f. MAXIMUM WEIGHT g. SERVICE/COMPONENT
ARMY
NAVY
USMC
USAF
USCG
REGULAR
RESERVE
NATIONAL GUARD
h. DATE SCREENED
(YYYYMMDD)
lbs.
(39) (Females only) Abnormal PAP smear or gynecological problem (4)
PREVIOUS EDITION IS OBSOLETE.
The public reporting burden for this collection of information is estimated to average 10 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 Directorate (0704-0413). 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.
Reset
DD FORM 2807-2, OCT 2003
Page 3 of 6 Pages
2a. (Continued) HAVE YOU EVER HAD OR DO YOU NOW HAVE: YES NO YES NO
(58) Anorexia or other eating disorder (4)
LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX) SOCIAL SECURITY NUMBER
(59) Cracked bone or fracture(s) (4)
(60) Bursitis (4)
(61) Braces (If you wear or are planning on obtaining braces for
your teeth, have the orthodontist submit a letter stating
that braces will be removed before active duty date;
release form and sample format can be found in the
Recruiter's Medical Guide.)
(62) Loss of finger, toe or part thereof (4)
(63) Loss of the ability to fully flex (bend) or fully extend a finger,
toe or other joint (4)(1)(7)
(64) Shoulder, knee, or elbow problem (out of place) (4)(1)(7)
(65) Locking of the knee or other joint (4)(1)(7)
(66) Giving way of knee or other joint (4)(1)(7)
(67) Cataracts or surgery for cataracts (4)
(68) Eye surgery, including radial keratotomy, lens implant or
other eye surgery to improve your vision (4)
(69) Collapsed lung or other lung condition (4)
(73) Do you smoke? (If yes:)
(a) Type
Cigarettes Cigars Smokeless tobacco
(b) How many per day?
(74) Evaluation, treatment, or hospitalization for substance use,
abuse, addiction or dependence (including illegal drugs,
prescription medications, or other substances)
b. EXPLAIN ALL "YES" ANSWERS TO QUESTIONS (1) - (75) ABOVE. (Describe answer(s), give date(s) of problems, name doctor(s), clinic(s), hospital(s),
treatment given and current medical status. Attach additional sheet(s) if necessary.)
(57) Absence or removal of the spleen, or rupture or tear of the
spleen without removal (4)
(75) Any illnesses, surgery, or hospitalization not listed above
(70) Bed wetting since age 12 (4)
(72) Taken medication, drugs, or any substance to improve
attention, behavior, or physical performance (2)(1)(6)
MEDICAL PRESCREEN
(c) Date last used
(71) Evaluation, treatment, or hospitalization for alcohol abuse,
dependence, or addiction (4)(6)
(55) Arthritis (4)
(56) Absence or disturbance of the sense of smell (4)
(50) Pain or swelling at the site of an old fracture (4)(1)(7)
(51) Perforated ear drum or tubes in ear drum(s) (4)
(52) Anemia (4)
(53) Ear surgery, to include mastoidectomy or repair of perforated
ear drum, hearing loss or need/use a hearing aid (4)
(54) Night blindness (4)
Reset
9. RECRUITING REPRESENTATIVE: I certify all information is complete and true to the best of my knowledge. I have conducted the medical
prescreening requirements as directed by service regulations.
a. NAME (If representative was used)
(Last, First, Middle Initial)
b. PAY GRADE c. SIGNATURE d. DATE SIGNED
(YYYYMMDD)
a. NAME(S) b. ADDRESS (Include ZIP Code) c. TELEPHONE (Include Area
Code)
b. SIGNATURE
c. DATE SIGNED
(YYYYMMDD)
I certify the information on this form is true and complete to the best of my knowledge and belief, and no person has
advised me to conceal or falsify any information about my physical and mental history.
I further understand that I may be requested to provide medical documentation regarding issues within my medical history.
I authorize any of the doctors, hospitals, clinics or insurance company(ies) to furnish the Department of Defense medical
authority a complete transcript of my medical record for purposes of processing my application for military service.
a. SIGNATURE b. DATE SIGNED
(YYYYMMDD)
a. NAME b. ADDRESS (Include ZIP Code) c. INSURANCE ID NUMBER
8. PARENT OR GUARDIAN SIGNATURE FOR MINOR (Mandatory) OR PARENT ASSISTING TO COMPLETE FORM (Voluntary)
DD FORM 2807-2, OCT 2003
Page 4 of 6 Pages
b. EXPLAIN ALL "YES" ANSWERS TO QUESTIONS (1) - (74) ABOVE. (Continued)
3. CURRENT PRIMARY CARE PHYSICIAN(S)/PRACTITIONER(S) AND/OR CLINIC(S) (Attach additional sheets if necessary)
a. NAME(S) b. ADDRESS (Include ZIP Code) c. TELEPHONE (Include Area
Code)
4. PREVIOUS PRIMARY CARE PHYSICIAN(S)
5. CURRENT INSURANCE PROVIDER
a. NAME(S) b. ADDRESS (Include ZIP Code) c. INSURANCE ID NUMBER
6. PREVIOUS INSURANCE PROVIDER(S)
MEDICAL PRESCREEN
LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX) SOCIAL SECURITY NUMBER
STOP AND READ: THE FOLLOWING STATEMENTS APPLY TO SIGNATURES AT ITEMS 7 AND 8
7. APPLICANT
a. NAME (Last, First, Middle Initial)
Reset
10. PHYSICIAN'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician shall comment on all positive answers in questions (1) - (74).
Physician may develop by interview any additional medical history deemed important, and record any significant findings here.)
a. COMMENTS
c. TYPED OR PRINTED NAME OF EXAMINER
e. DATE SIGNED
(YYYYMMDD)
d. SIGNATURE
11. MEDICAL OFFICER'S PRESCREENING COMMENTS: Based on information provided, further processing is:
a. ON PRESCREEN:
(1) AUTHORIZED (2) NOT JUSTIFIED (Permanent Disqualification (PDQ)):
(b) RJ Date (If applicable)
(a) Pending review of additional documentation
(a) Additional information needed (See DD Form 2808)
DD FORM 2807-2, OCT 2003
Page 5 of 6 Pages
LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX) SOCIAL SECURITY NUMBER
12. NUMBER OF
ATTACHED SHEETS
(a) Profile Serial ICD
(b) Process for Waiver (CMO initials)
(3) DEFERRED (See Comments above):
(CMO initials)
b. ON EXAM:
(1) APPROVED
(3) NOT JUSTIFIED:
(2) DEFERRED:/
(b) Information different than on prescreen
(c) Form not prescreened by MEPS
(4) MEPS USE:
(a) AE
(b) RE
(c) PRI
(d) N/A
MEDICAL PRESCREEN
Reset
13. COMMENTS (Continued)
DD FORM 2807-2, OCT 2003
Page 6 of 6 Pages
LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX) SOCIAL SECURITY NUMBER
MEDICAL PRESCREEN
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INSTRUCTIONS FOR DD FORM 2807-2, MEDICAL PRESCREEN OF (New York State)

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Completed 17 February 2021

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