Fillable This form must be completed electronically. Handwritten forms (Washington Headquarters Services)

Fill Online, Printable, Fillable, Blank This form must be completed electronically. Handwritten forms (Washington Headquarters Services) Form

Use Fill to complete blank online WASHINGTON HEADQUARTERS SERVICES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

This form must be completed electronically. Handwritten forms (Washington Headquarters Services)

On average this form takes 149 minutes to complete

The This form must be completed electronically. Handwritten forms (Washington Headquarters Services) form is 16 pages long and contains:

  • 0 signatures
  • 146 check-boxes
  • 529 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Washington Headquarters Services forms online.

BROWSE WASHINGTON HEADQUARTERS SERVICES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
This form must be completed electronically. Handwritten forms will not be accepted.
DD FORM 2796, OCT 2015
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 10 Pages
POST DEPLOYMENT HEALTH ASSESSMENT (PDHA)
PRIVACY ACT STATEMENT
INSTRUCTIONS:
You are encouraged to answer all questions. You must at least complete the first portion on who you are and when and where
you deployed. If you do not understand a question, please discuss the question with a health care provider.
DEMOGRAPHICS
Last Name
__________________________
First Name
______________________
Middle Initial
____
Social Security Number
______________________
Today’s Date
(
dd/mmm/yyyy
) ____________________
Date of Birth
(
dd/mmm/yyyy
) ___________________
Gender
Male
Female
Service Branch Component Pay Grade
Air Force
Active Duty
E1
O1
W1
Army
National Guard
E2
O2
W2
Navy
Reserves
E3
O3
W3
Marine Corps
Civilian Government Employee
E4
O4
W4
Coast Guard
E5
O5
W5
Civilian Expeditionary Workforce (CEW)
E6
O6
USPHS
E7
O7
Other
Other Defense Agency List: _________________
E8
O8
E9
O9
O10
Home station/unit:
_________________________________
Current contact information: Point of contact who can always reach you:
Phone: ______________________________ Name: ________________________________
Cell: ________________________________ Phone: _______________________________
DSN: _______________________________ Email: ________________________________
Email: _______________________________ Address: ______________________________
Address: _____________________________ ______________________________
_____________________________ ______________________________
_____________________________
PLEASE ANSWER ALL QUESTIONS BASED ON YOUR MOST RECENT DEPLOYMENT
Date arrived theater
(
dd/mmm/yyyy
) ________________
Date departed theater
(
dd/mmm/yyyy
) _____________
Location of operation
To what areas were you mainly deployed?
(Please list all that apply, including the number of months spent at each location.)
Country 1 __________________________________________ Time at location (
months
) __________________
Country 2 __________________________________________ Time at location (
months
) __________________
Country 3 __________________________________________ Time at location (
months
) __________________
Country 4 __________________________________________ Time at location (months) __________________
Country 5 __________________________________________ Time at location (months) __________________
This statement serves to inform you of the purpose for collecting the personal information required by the DD Form 2796, Post Deployment Health
Assessment (PDHA), and how it will be used.
AUTHORITY:
10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 10 U.S.C. 1074f, Medical Tracking System for Members
Deployed Overseas; DoDD 1404.10, DoD Civilian Expeditionary Workforce; DoDD 6490.02E, Comprehensive Health Surveillance; and E.O. 9397
(SSN), as amended.
PURPOSE:
To collect information on your physical and mental health status after a deployment in a combat, contingency, or other operation
outside of the United States, and to assist health care providers in administering present or future care.
ROUTINE USES:
Use and disclosure of your records outside of DoD may occur in accordance with the DoD Blanket Routine Uses published at
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx, and as permitted by the Privacy Act of 1974, as amended (5 U.S.C.
552a(b)). Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule
(45 CFR Parts 160 and 164), as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment,
payment, and healthcare operations.
DISCLOSURE:
Voluntary. However, if you choose not to provide the requested information comprehensive health care services may not be
possible or administrative delays may occur. Care will not be denied.
S A M P L E
This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
DD FORM 2796, OCT 2015 Page 2 of 10 Pages
1. Overall, how would you rate your health during the PAST MONTH?
Excellent
Very Good
Good
Fair
Poor
2. Compared to before this deployment, how would you rate your health in general now?
Much better now than before I deployed
Somewhat better now than before I deployed
About the same as before I deployed
Somewhat worse now than before I deployed Please explain: ___________________________________________________
Much worse now than before I deployed Please explain: ___________________________________________________
3. How often did you smoke tobacco (for example cigarettes, cigars, pipe, or hookah) during your deployment?
Just about every day
Some days
Not at all
4. Were you wounded, injured, assaulted or otherwise hurt during your deployment?
Yes
No
If yes, are you still having any problems or concerns related to this event?
Yes
No
If yes, please explain: __________________________________________________________________________________________
5. During your deployment:
a. Did you ever feel like you were in great danger of being killed?
Yes
No
b. Did you encounter dead bodies or see people killed or wounded during this deployment?
Yes
No
c. Did you engage in direct combat where you discharged a weapon?
Yes
No
6. How many times during your deployment did you visit a health care provider for a medical or dental health problem/concern?
No visits
1 visit
2-3 visits
4-5 visits
6 or more
7. During this deployment did you receive care for combat stress or a mental health problem/concern?
Yes
No
If yes, please explain: ___________________________________________________________________________________________
8. During this deployment, did you have to spend one or more nights in a hospital as a patient?
Yes
No
Reason/dates: _________________________________________________________________________________________________
9. During the PAST MONTH, how difficult have physical health problems (illness or injury) made it for you to do your work or other
regular daily activities?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
10.a. During this deployment, did any of the following events happen to you?
(Mark all that apply)
(1) Blast or explosion (e.g., IED, RPG, EFP, land mine, grenade, etc.)?
Yes
No
If yes, please estimate your distance from the closest blast or explosion:
Less than 25 meters (82 feet)
25-50 meters (82-164 feet)
50-100 meters (164-328 feet)
More than 100 meters (328 feet)
(2) Vehicular accident/crash (any vehicle including aircraft)?
Yes
No
(3) Fragment wound or bullet wound?
a. Head or neck
Yes
No
b. Rest of body
Yes
No
(4) Other injury (e.g., sports injury, accidental fall, etc.)?
Yes
No
If yes to any of the above, please explain: ___________________________________________________________________________
10.b. As a result of any of the events in 10.a., did you receive a jolt or blow to your head that IMMEDIATELY resulted in:
(1) Losing consciousness (“knocked out”)?
Yes
No
If yes, for about how long were you knocked out?
Less than 5 min
5-30 min
more than 30 min
(2) Losing memory of events before or after the injury?
Yes
No
(3) Seeing stars, becoming disoriented, functioning
differently, or nearly blacking out?
Yes
No
10.c. How many total times during this deployment did you receive a blow or jolt to your head?
(only answer if you had a yes to any of the questions on 10a.)
0
1
2
3
more than 3 (list number of times) _____________
S A M P L E
This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
DD FORM 2796, OCT 2015 Page 3 of 10 Pages
11. During the PAST MONTH, how much have you been bothered by any of the following problems?
Symptom
Not bothered at
all
Bothered a
little
Bothered a
lot
a. Stomach pain
b. Back pain
c. Pain in the arms, legs, or joints (knees, hips, etc.)
d. Menstrual cramps or other problems with your periods (Women only)
e. Headaches
f. Chest pain
g. Dizziness
h. Fainting spells
i. Feeling your heart pound or race
j.
Wheezing, shortness of breath, or difficulty breathing (other than asthma)
k. Pain or problems during sexual intercourse
l. Constipation, loose bowels, or diarrhea
m. Nausea, gas, or indigestion
n. Feeling tired or having low energy
o. Trouble sleeping
p. Trouble concentrating on things (such as reading a newspaper or watching television)
q. Memory problems
r. Balance problems
s. Noises in your head or ears (such as ringing, buzzing, crickets, humming, tone, etc.)
t. Trouble hearing
u. Sensitivity to bright light
v. Becoming easily annoyed or irritable
w. Fever
x. Cough lasting more than 3 weeks
y. Numbness or tingling in the hands or feet
z. Hard to make up your mind or make decisions
aa. Watery, red eyes
bb. Dimming of vision, like the lights were going out
cc. Skin rash and/or lesion
dd. Pain with urination, frequency of urination, or strong urge to urinate
ee. Bleeding gums, tooth pain, or broken tooth
12. a. Over the PAST MONTH, what major life stressors have
None or
you experienced that are a cause of significant concern
Please list and explain:
___________________________
or make it difficult for you to do your work, take care of
things at home, or get along with other people (for example, ______________________________________________
serious conflicts with others, relationship problems,
or a legal, disciplinary or financial problem)? ______________________________________________
b. Are you currently in treatment or getting professional
Yes
No
help for this concern?
13. What prescription or over-the-counter medications (including
Please list: ____________________________________
herbals/supplements) for sleep, pain, combat stress, or a
mental health problem are you CURRENTLY taking?
____________________________________________________
None
14. a. How often do you have a drink containing alcohol?
Never
Monthly or less
2-4 times a month
2-3 times per week
4 or more times a week
b. How many drinks containing alcohol do you have on a typical day when you are drinking?
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
c. How often do you have six or more drinks on one occasion?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
15. Have you ever had any experience that was so frightening, horrible, or upsetting that, in the PAST MONTH, you:
a. Have had nightmares about it or thought about it when you did not want to?
Yes
No
b. Tried hard not to think about it or went out of your way to avoid situations that remind you of it?
Yes
No
c. Were constantly on guard, watchful or easily startled?
Yes
No
d. Felt numb or detached from others, activities, or your surroundings?
Yes
No
S A M P L E
This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
DD FORM 2796, OCT 2015 Page 4 of 10 Pages
16. Over the LAST 2 WEEKS, how often have you been bothered by the following problems?
Not at all Few or several days More than half the days Nearly every day
a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
17. Are you worried about your health because you believe you were
Yes
No
exposed to something in the environment while deployed?
If yes, please explain: ___________________________________________________________________________________________
18. Do you think you were exposed to any chemical, biological,
Yes
No
or radiological warfare agents during this deployment?
If yes, please explain: __________________________________________________________________________________________
19. Were you in a vehicle hit by a depleted uranium (DU) round;
Yes
No
inside a destroyed vehicle that contained DU;
Don’t know
or closely inspect such a vehicle?
If yes, please explain: __________________________________________________________________________________________
20. Were you told to take medicines to prevent malaria?
Yes
No
If yes, please indicate which medicines you took and whether you took all pills as directed. (Mark all that apply)
Anti-malarial medications received Took all pills?
Chloroquine (Aralen®)
Yes
No
Doxycycline (Vibramycin®)
Yes
No
Malarone®
Yes
No
Mefloquine (Lariam®)
Yes
No
Primaquine
Yes
No
Other: __________________
Yes
No
Given pills but do not
Yes
No
know drug name
21. Were you bitten or scratched by an animal during your deployment?
Yes
No
If yes, please explain what kind of animal was involved, your injury, and what happened:
___________________________________________________________________________________
___________________________________________________________________________________
22. Would you like to schedule an appointment with a health care provider to discuss any health concern(s)?
Yes
No
23. Are you interested in receiving information or assistance for a stress, emotional or alcohol concern?
Yes
No
24. Are you interested in receiving assistance for a family or relationship concern?
Yes
No
25. Would you like to schedule a visit with a chaplain or a community support counselor?
Yes
No
S A M P L E
This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
DD FORM 2796, OCT 2015 Page 5 of 10 Pages
Health Care Provider Only – Provider Review, Interview, Assessment, and Recommendations:
Deployer reports arriving in theater on: _______________________ Deployer reports departing theater on: _______________________
1. Address concerns identified on deployer questions 1 and 2.
Deployer
question
Not
answered
Deployer
indicated
concern
Deployer’s
response
or concern
Provider
comments
(if
indicated)
Self health rating
Change in health post-deployment
2. Address wounds, injuries, assaults, etc., occurring during deployment as reported on deployer question 4.
a. Did deployer mark that he/she is still having a problem
Yes
or concern related to a wound, injury, or assault that
No (
go to block 3)
occurred during their deployment?
Not answered by deployer
b. Refer for evaluation?
Yes (complete blocks 19 and 20)
No
Already under care
Already has referral
No significant impairment
Other reason (explain):
_________________________
3. Deployment experiences as reported in deployer question 5. Consider in overall assessment; ask follow-up questions as indicated.
Deployer
question
Not
answered
Yes
response
Provider comments (if
indicated)
Danger of being killed
Encountered bodies or saw people killed or wounded
In direct combat and discharged weapon
4. Address concerns identified on deployer questions 6 through 9.
Deployer
question
Not
answered
Deployer
indicated
concern
Deployer’s
response
or concern
Provider comments (if
indicated)
Health care visits during deployment
Care for combat stress/mental health
Hospitalized during deployment
Physical limitations/problems
5. Deployment injury and concussion risk assessment.
a. Did deployer have an injury based on their
Yes
responses to question 10.a.?
No (
go to block 6)
b. Did deployer have a possible concussion based on
Yes
their responses to questions 10.a. through 10.c.?
No (
go to block 6)
c. Evaluate injury history and concussion-related experiences and symptoms.
Refer for evaluation?
Yes (complete blocks 19 and 20)
No
Already under care
Already has referral
No significant impairment
Other reason (explain):
________________________
S A M P L E
This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
DD FORM 2796, OCT 2015 Page 6 of 10 Pages
6. Post-deployment general symptoms/health concerns.
List of symptoms reported as “Bothered a Lot” on Deployer Questions 11a.
through 11ee.
List of symptoms reported as “Bothered a Little” on Deployer Questions 11a.
through 11ee.
Physical symptom (PHQ-15) severity score for Deployer Questions 11a.
through 11o.
Minimal < 4 Low 5 - 9 Medium 10 - 14 High ≥ 15
Deployer’s total
_____ _____ _____ _____
a. Does deployer have evidence of high generalized post-deployment
Yes
physical symptoms (a score of ≥ 15 on the PHQ-15 physical
No
symptoms scale - deployer questions 11a. - 11o.) or is “bothered
Not answered by deployer
a lot” by specific symptoms listed in 11a. – 11ee.?
b. Based on deployer’s responses to deployer questions
Yes (complete blocks 19 and 20)
11a. through 11ee. is a referral indicated?
No
Already under care
Already has referral
No significant impairment
Other reason (explain):
________________________
7. Major life stressor as reported on deployer question 12.
a. Did deployer mark they have a concern or a
Yes Deployer’s concern: _________________________
difficulty with a major life stressor?
No (
go to block 8)
Not answered by deployer
b. If yes,
ask
additional questions to determine level of problem: ________________________________________________________
c. Consider need for referral. Referral indicated?
Yes (complete blocks 19 and 20)
No
Already under care
Already has referral
No significant impairment
Other
reason (explain):
________________________
8. Self-reported history of prescription or over-the-counter medications as described on deployer question 13.
Deployer
question
Not
answered
Yes
response
Deployer’s
response
Provider comments (if
indicated)
Medications
S A M P L E
This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
DD FORM 2796, OCT 2015 Page 7 of 10 Pages
9. Alcohol use as reported in deployer question 14.
a. Deployer’s AUDIT-C screening score was ______.
(If score between
Not answered
0-4 (men) or 0-3 (women) nothing required, go to block 10).
Number of drinks per week:
_____________
Maximum number of drinks per occasion:
___
_______
___
Based on the AUDIT-C score and assessment of alcohol use, follow the guidance below:
Alcohol Use Intervention
Matrix
Assess Alcohol Use
AUDIT-C Score
Men 5 - 7
Women 4 - 7
AUDIT-C Score
Men and Women ≥
8
Alcohol use WITHIN recommended limits:
Men: ≤ 14 drinks per week
OR
≤ 4 drinks on any occasion
Women: ≤ 7 drinks per week
OR
≤ 3 drinks on any occasion
Advise patient to stay below
recommended limits
Refer if indicated for further evaluation
AND
conduct BRIEF counseling*
Alcohol use EXCEEDS recommended limits:
Men: > 14 drinks per week or > 4 drinks on any occasion
Women: > 7 drinks per week or > 3 drinks on any occasion
Conduct BRIEF counseling*
AND
consider referral for further evaluation
*
BRIEF
counseling
: B
ring attention to elevated level of drinking;
R
ecommend limiting use or abstaining;
I
nform about the effects of alcohol
on health;
E
xplore and help/support in choosing a drinking goal;
F
ollow-up referral for specialty treatment, if indicated.
b. Referral indicated for evaluation?
Yes (complete blocks 19 and 20)
No Provide education/awareness as needed.
State reason if AUDIT-C score was 8+:
Already under care
Already has referral
No significant impairment
Other reason (explain):
________________________
10. PTSD screening as reported in deployer question 15.
a. Are two or more of the deployer’s responses
Yes
to questions 15a. through 15d. “yes?”
No
(go to block 11)
Not answered by deployer
b. If yes, ask additional questions to determine extent of problem: _______________________________________________________
c. Consider need for referral. Referral indicated?
Yes (complete blocks 19 and 20)
No
Already under care
Already has referral
No significant impairment
Other
reason (explain):
________________________
11. Depression screening as reported in deployer question 16.
a. Did deployer mark “more than half the days” or
Yes
“nearly every day” on question 16a. or 16b.?
No
(go to block 12)
Not answered by deployer
b. If yes, ask additional questions to determine extent of problem; briefly describe results: _____________________________________
c. Consider need for referral. Referral indicated?
Yes (complete blocks 19 and 20)
No
Already under care
Already has referral
No significant impairment
Other
reason (explain):
________________________
S A M P L E
This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
DD FORM 2796, OCT 2015 Page 8 of 10 Pages
12. Environmental and exposure concern/assessment as reported in deployer questions 17 and 18.
a. Did deployer indicate a worry or possible exposure?
Yes
No (go to block 13)
If yes, mark deployer’s exposure
concern(s)
Animal bites
Paints
Animal bodies (dead)
Pesticides
Chlorine gas
Radar/Microwaves
Depleted uranium
Sand/dust
Excessive vibration
Smoke from burning trash or feces
Fog oils (smoke screen)
Smoke from oil fire
Garbage
Solvents
Human blood, body fluids, body parts, or dead bodies
Tent heater smoke
Industrial pollution
Vehicle or truck exhaust fumes
Insect bites
Chemical, biological, radiological warfare agent
Ionizing radiation
Other exposures to toxic chemicals or materials, such as
ammonia, nitric acid, etc. Please list:
JP8 or other fuels
Lasers
Loud noises
b. If yes, referral indicated?
Yes (complete blocks 19 and 20)
No (provide risk education)
When an individual’s medical condition(s) or concern may be associated
Already under care
with possible occupational or environmental exposures during a deployment,
Already has referral
a Periodic Occupational and Environmental Monitoring Summary (POEMS)
No significant impairment
document may be available for review online at https://mesl.apgea.army.mil/mesl/ .
Other reason (explain):__
________________
13. Depleted uranium (DU) as reported in deployer question 19.
a. Did deployer mark either “yes” or
Yes
“don’t know to questions19?
No
(go to block 14)
b. If yes, based on details of event and extent
Yes (complete blocks 19 and 20)
of exposure is referral to PCM for completion
No (provide risk education)
of DD Form 2872 (DU Questionnaire) and
Already under care
possible 24-hour urinalysis indicated?
Already has referral
No significant impairment
Other
reason (explain):
_______________________
14. Malaria prophylaxis review as reported in deployer question 20.
Deployer reports having deployed to: _________________________
a. Deployment location required malaria prophylaxis?
Yes
No
(go to block 15)
b. Did deployer receive anti-malarial prophylaxis
Yes
(go to block 15)
No
AND report compliance?
c. If no, determine need for prophylaxis. Prescription indicated?
Yes (complete blocks 19 and 20)
No (briefly state reason):
_________________________________
15. Animal bite (rabies risk) as reported on deployer question 21.
a. Did deployer mark “yes” on animal bite/scratch?
Yes
No
(go to block 16)
b. If yes, based on details of event and care received
Yes (complete blocks 19 and 20)
is a referral and/or follow-up indicated?
No (provide risk education)
Note: Rabies incubation period can be months to
Was appropriately treated
years. Rabies prophylaxis can begin at anytime.
Already under care
Already has referral
Situation was not a risk for rabies
Other
reason (explain):
_______________________
S A M P L E
This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
DD FORM 2796, OCT 2015 Page 9 of 10 Pages
16. Suicide risk evaluation.
a.
Ask
“Over the
PAST MONTH
, have you been bothered
Yes
by thoughts that you would be better off dead or of
No (go to block 17)
hurting yourself in some way?”
b. If 16.a. was yes,
ask:
“How often have you
Few or several days
been bothered by these thoughts?”
More than half of the time
Nearly every day
c. If 16.a. was yes,
ask:
“Have you had thoughts of
Yes
(If yes, ask questions 16d. through 16g.)
actually hurting yourself?”
No (If no thoughts of self-harm, go to block 17)
d.
Ask
“Have you thought about how you might actually hurt yourself?”
Yes How? ____________________________________
No
e.
Ask
“There’s a big difference between having a thought and
Not at all likely
acting on a thought. How likely do you think it is that you will
Somewhat likely
act on these thoughts about hurting yourself or ending
Very likely
your life over the next month?”
f.
Ask
“Is there anything that would prevent or
Yes What? ___________________________________
keep you from harming yourself?”
No
g.
Ask
“Have you ever attempted to harm yourself in the past?”
Yes How? ____________________________________
No
h. Conduct further risk assessment
(e.g., interpersonal conflicts,
social isolation, alcohol/substance abuse, hopelessness, Comments: _____________________________________
severe agitation/anxiety, diagnosis of depression or other
psychiatric disorder, recent loss, financial stress, ______________________________________________
legal disciplinary problems, or serious physical illness).
i.
Does deployer pose a current risk for harm to self?
Yes (complete blocks 19 and 20)
No
17. Violence/harm risk evaluation.
a.
Ask,
“Over the past month have you had thoughts or
Yes
concerns that you might hurt or lose control with someone?”
No
(go to block 18)
If yes,
ask
additional questions to determine
extent of problem (target, plan, intent, past history) Comments: _____________________________________________________
b. Does member pose a current risk to others?
Yes (complete blocks 19 and 20)
No (briefly state reason): _________________________
S A M P L E
This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
DD FORM 2796, OCT 2015 Page 10 of 10 Pages
18. Deployer issues with this assessment (mark as
appropriate):
Deployer declined to complete form
Deployer declined to complete interview/assessment
Assessment and Referral: After review of deployer’s responses
and interview with the deployer, the assessment and need for
further evaluation is indicated in blocks 19 through 22.
19. Summary of provider’s
identified
concerns needing
referral
< Mark all that
apply>
Yes No
a. None Identified
b. Physical health
c. Dental health
d. Concussion
e. Mental health symptoms
f. Alcohol use
g. PTSD symptoms
h. Depression symptoms
i. Environment/work exposure
j. Depleted uranium
k. Malaria prophylaxis
l. Risk of self-harm
m. Risk of violence
n. Other, list:
20. Recommended
referral(s)
< Mark all that apply
even if
deployer does not
desire>
Within
24 hours
Within
7 days
Within
30 days
a. Primary Care, Family Practice,
Internal Medicine
b. Behavioral Health in Primary Care
c. Mental Health Specialty Care
d. Dental
e. Other specialty care:
Audiology
Dermatology
OB/GYN
Physical Therapy
TBI/Rehab Med
Podiatry
Other, list
f. Case Manager / Care Manager
g. Substance Abuse Program
h. Immunization clinic
i. Laboratory
j. Other, list:
21. Comments
: _________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
22. Address requests as reported on deployer questions 22 through 25.
Deployer
question
Not
answered
Yes
response
Comments (if
indicated)
Request medical appointment
Request info on stress/emotional/alcohol
Family/relationship concern assistance
Chaplain/counselor visit request
23. Supplemental services recommended / information
provided
Appointment Assistance
Family Support
Information on post-deployment blood specimen requirement
Military One Source
Contract Support: _____________________________________
TRICARE Provider
Community Service: ___________________________________
VA Medical Center or Community Clinic
Chaplain
Vet Center
Health Education and Information
Other, list:
Health Care Benefits and Resources Information
In Transition
Provider’s Name:
___________________________________________ Date (
dd/mmm/yyyy
) _____________________________
Title:
MD or DO
PA
Nurse Practitioner
Adv Practice Nurse
IDMT
IDC
IDHS
I certify that this review process has been completed. This visit is coded by DOD0212.
S A M P L E
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

This form must be completed electronically. Handwritten forms (Washington Headquarters Services)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 14 June 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document