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DD FORM 2795, OCT 2015 PREVIOUS EDITION IS OBSOLETE Page 1 of 7 Pages
PRE-DEPLOYMENT HEALTH ASSESSMENT
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 you will
deploy. 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
O
10
Current contact information: Point of contact who can always reach you:
Phone: ______________________________ Name: ________________________________
Cell: ________________________________ Phone: _______________________________
DSN: _______________________________ Email: ________________________________
Email: _______________________________ Address: ______________________________
Address: _____________________________ ______________________________
_____________________________ ______________________________
_____________________________
Estimated date of upcoming deployment (dd/mmm/yyyy) ________________
List country you are deploying to (if known): ________________________________________
Name of operation (if known): __________________________
How many deployments have you done before?
None 1 2 3 4 5 6 or more
(if previous question was answered as one or more)
When did you return from your last deployment? (Mmm yyyy)
___________________
This statement serves to inform you of the purpose for collecting the personal information required by the DD Form 2795, Pre-Deployment Health
Assessment, 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 prior to a deployment in a combat, contingency, or other operation
outside of the United States, and to assist health care providers i
n 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 request
ed informat
ion 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 2795, OCT 2015 Page 2 of 7 Pages
1. Overall, how would you rate your health during the PAST MONTH?
Excellent Very Good Good Fair Poor
2. Are you CURRENTLY on a profile, limited duty, waiting on a Yes For what reason? ___________________________
MOS/Medical Retention Board (MMRB) decision, or being No
referred to a medical evaluation board (MEB) or physical Don’t know
evaluation board (PEB)?
3. How often do you smoke tobacco (for example Just about every day
cigarettes, cigars, pipe or hookah)? Some days
Not at all
4. What problems, questions or concerns do you have Please explain: _________________________________
about your medical, dental, or mental health? None
5. FEMALES ONLY – Are you pregnant or is Don’t know
there a chance you could be pregnant? Yes
No
6. In the PAST YEAR did you receive care Yes Please explain: ____________________________
for a head injury? No
7. What prescription or over-the- counter medications Please list: ____________________________________
(including herbals/supplements) for sleep, pain,
combat stress, or mental health conditions or __________________________________________
concerns are you CURRENTLY taking? None
8. In the PAST YEAR did you receive care for any mental health Yes Please explain: ____________________________
condition or concern such as, but not limited to post traumatic No
stress disorder (PTSD),depression, anxiety disorder, alcohol
abuse or substance abuse?
9. 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. Noises in your head or ears (such as ringing, buzzing, crickets, humming, tone, etc.)
b. Trouble hearing
10. 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
11. 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
NOTE: If 2 or more items on 11a. through 11d. are marked yes, continue to answer items 11e. through 11v.
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 2795, OCT 2015 Page 3 of 7 Pages
Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each question
carefully and check the box for how much you have been bothered by that problem in the PAST MONTH. Please answer all items.
Not at all A little bit Moderately Quite a bit Extremely
11e. Repeated, disturbing memories, thoughts, or images of a
stressful experience from the past?
11f. Repeated, disturbing dreams of a stressful experience from
the past?
11g. Suddenly acting or feeling as if a stressful experience were
happening again (as if you were reliving it)?
11h. Feeling very upset when something reminded you of a
stressful experience from the past?
11i. Having physical reactions (e.g., heart pounding, trouble
breathing, or sweating) when something reminded you of a
stressful experience from the past?
11j. Avoid thinking about or talking about a stressful experience
from the past or avoid having feelings related to it?
11k. Avoid activities or situations because they remind you of a
stressful experience from the past?
11l. Trouble remembering important parts of a stressful
experience from the past?
11m. Loss of interest in things that you used to enjoy?
11n. Feeling distant or cut off from other people?
11o. Feeling emotionally numb or being unable to have loving
feelings for those close to you?
11p. Feeling as if your future will somehow be cut short?
11q. Trouble falling or staying asleep?
11r. Feeling irritable or having angry outbursts?
11s. Having difficulty concentrating?
11t. Being “super alert” or watchful, on guard?
11u. Feeling jumpy or easily startled?
Not difficult at all Somewhat difficult Very difficult Extremely difficult
11v. How difficult have these problems (11e. through
11u) made it for you to do your work, take care of
things at home, or get along with other people?
12. 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
NOTE: If 12a. or 12b. are marked “More than half the days” or “Nearly every day,” continue to answer items 12c. through 12i.
Over the LAST 2 WEEKS, how often have you been bothered by any
of the following problems?
Not at all
Few or several
days
More than half
the days
Nearly every day
12c. Trouble falling/staying asleep, sleep too much.
12d. Feeling tired or having little energy.
12e. Poor appetite or overeating.
12f. Feeling bad about yourself – or that you are a failure or have
let yourself or your family down.
12g. Trouble concentrating on things, such as reading the
newspaper or watching television.
12h. Moving or speaking so slowly that other people could have
noticed. Or the opposite – being so fidgety that you have
been moving around a lot more than usual.
Not difficult
at all
Somewhat
difficult
Very difficult
Extremely
difficult
12i. How difficult have these problems (12a.through12h.) made it
for you to do your work, take care of things at home, or get
along with other people?
13. 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?
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 2795, OCT 2015 Page 4 of 7 Pages
Health Care Provider Only – Provider Review, Interview, Assessment, and Recommendations:
Deployer is deploying to ______________________. Has deployed _______ times before. Last returned _________________
1. Address concerns identified on deployer questions 1 through 8.
Deployer question
Not
answered
Deployer indicated
concern or yes
Deployer’s response
Provider comments
(if indicated)
Self health rating
MEB or PEB
Medical, dental, or mental health concern
Pregnancy
Head injury
Medications
History of mental health care
2. Hearing and tinnitus as reported in deployer question 9.
a. Did deployer mark he/she bothered a little Yes
or a lot in the past month by “noises in head No (go to block 3)
or ears” or “trouble hearing”?
b. If yes, referral indicated? Yes (complete blocks 11 and 12)
No Already under care
Already has referral
No significant impairment
Other reason (explain): _________________________
3. Alcohol use as reported in deployer question 10.
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 4).
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: Bring attention to elevated level of drinking; Recommend limiting use or abstaining; Inform about the effects of alcohol
on health; Explore and help/support in choosing a drinking goal; Follow-up referral for specialty treatment, if indicated.
b. Referral indicated for evaluation? Yes (complete blocks 11 and 12)
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): _________________________
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 2795, OCT 2015 Page 5 of 7 Pages
4. PTSD screening as reported in deployer question 11.
a. Did deployer mark yes on two or more of Yes
questions 11a. through 11d.? No (go to block 5)
Not answered by deployer
b. If yes, deployer’s responses to questions 11e. through 11u. resulted in a PCL-C score of _________ and the deployer’s response to level
of impairment with life events (11v.) is indicated in the table below.
11e. through 11v. were not answered or are incomplete.
Based on the PCL-C score, the deployer’s level of functioning, and your exploration of responses, follow the guidance below:
Post-Traumatic Stress Disorder Intervention Matrix
Self-Reported
Level of Functioning
PCL-C Score <30
(Sub-threshold or
no Symptoms)
PCL-C Score 30-39
(Mild Symptoms)
PCL-C Score 40-49
(Moderate Symptoms)
PCL-C Score ≥ 50
(Severe Symptoms)
Not Difficult at All
or
Somewhat Difficult
No intervention Provide PTSD education*
Consider referral for
further evaluation
AND
provide PTSD education*
Very Difficult
to
Extremely Difficult
Assess need for further
evaluation
AND
provide PTSD education*
Consider referral for further evaluation
AND
provide PTSD education*
Refer for further evaluation
AND
provide PTSD education*
* PTSD Education = Reassurance/supportive counseling, provide literature on PTSD, encourage self-management activities, and counsel
deployer to seek help for worsening symptoms.
c. Referral indicated? Yes (complete blocks 11 and 12)
No
Already under care
Already has referral
No significant impairment
Other reason (explain): _____________________________
5. Depression screening as reported in deployer question 12.
a. Did deployer mark “More than half the days” or Yes
“Nearly every day” on question 12a. or 12b.? No (go to block 6)
Not answered by deployer
b. If yes, deployer’s responses to questions 12a. through 12h. resulted in a total PHQ-8 score of _________ and the deployer’s response to
level of impairment with life events (12i.) is indicated in the table below.
12c. through 12i. were not answered or incomplete.
Based on the PHQ-8 score, deployer’s level of functioning, and exploration of responses, follow the guidance below:
Depression Intervention Matrix
Self-Reported
Level of Functioning
PHQ-8 Score 1-4
(No Symptoms)
PHQ-8 Score 5-9
(Sub-Threshold Symptoms)
PHQ-8 Score 10-14
(Mild Symptoms)
PHQ-8 Score 15-18
(Moderate Symptoms)
PHQ-8 Score 19-24
(Severe Symptoms)
Not Difficult at All
or
Somewhat Difficult
No intervention Depression education*
Consider referral for
further evaluation
AND
provide depression
education*
Consider referral for
further evaluation
AND
provide depression
education*
Very Difficult
to
Extremely Difficult
Assess need for further evaluation
AND
provide depression education*
Consider referral for
further evaluation
AND
provide depression
education*
Consider referral for
further evaluation
AND
provide depression
education*
Refer for further
evaluation
AND
provide depression
education*
* Depression Education = Reassurance/supportive counseling, provide literature on depression, encourage self-management activities,
and counsel deployer to seek help for worsening symptoms.
c. Referral indicated? Yes (complete blocks 11 and 12)
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 2795, OCT 2015 Page 6 of 7 Pages
6. Major life stressor as reported on deployer question 13.
a. Did deployer mark they have a concern or a Yes Deployer’s concern: ________________________
difficulty with a major life stressor? No (go to block 7)
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 11 and 12)
No
Already under care
Already has referral
No significant impairment
Other reason (explain): _________________________
7. 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 8)
hurting yourself in some way?”
b. If 7.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 7.a. was yes, ask: “Have you had thoughts of Yes (If yes ask questions 7d. through 7g.)
actually hurting yourself?” No (If no thoughts of self-harm, go to block 8)
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 11 and 12)
No
8. 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 9)
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 11 and 12)
No (briefly state reason): __________________________
9. Medical History Review – if available, hard copy and/or electronic Completed
health records (including DD2766 and SF-600 entries, and most No health records available
recent past deployment health assessments).
a. Significant findings related to ability to deploy: ______________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
b. Evidence of deployment limiting conditions or medications? 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 2795, OCT 2015 Page 7 of 7 Pages
10. 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 11 through 14.
11. Summary of provider’s identified
concerns needing referral
< Mark all that apply>
Yes No
a. None Identified
b. Physical health
c. Dental health
d. Alcohol use
e. PTSD symptoms
f. Depression symptoms
g. Mental health symptoms
h. Risk of self-harm
i. Risk of violence
j. Other, list:
12. 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:
13. Comments: ________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
14. Medical assessment/disposition:
Deployable
Deployable at present, but requires medical readiness updates. May delay or make undeployable, e.g., pregnancy test, immunizations, overdue
Pap test, dental exam, PHA, outdated eyeglass prescription, (add comments – block 15).
Not Deployable – potentially disqualifying condition requiring additional evaluation (add comments – block 15).
Not Deployable – other (add comments – block 15).
15. Comments (Mandatory for any type of Not Deployable disposition).
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
16. Supplemental services recommended / information provided
Appointment Assistance Family Support
Contract Support: _____________________________________ Military One Source
Community Service: ___________________________________ TRICARE Provider
Chaplain VA Medical Center or Community Clinic
Health Education and Information Vet Center
Health Care Benefits and Resources Information Other, list:
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 DOD0211.
S A M P L E
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Completed 25 September 2021

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