DD Form 2351 DoD Medical Examination Review Board (DoDMERB) Report of

DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)
REPORT OF MEDICAL EXAMINATION

OMB No. 0704-0396
OMB approval expires
Sep 30, 2006

(Please read Privacy Act Statement before completing this form.)

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 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.

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.
DODMERB USE ONLY

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.
APPLICANT DATA
1. DATE OF EXAMINATION (YYYYMMDD)

2. NAME (Last, First, Middle Initial)

4. DATE OF BIRTH (YYYYMMDD)

5. AGE

3. SOCIAL SECURITY ACCOUNT NUMBER

7. RACE (Ethnic Group)

6. SEX

9. STATUS (X one)

8. ADDRESS INFORMATION (If left blank will delay processing)
a. APPLICANT MAILING ADDRESS (Include ZIP Code)

ACTIVE DUTY

CIVILIAN

RESERVE/GUARD

10. EXAMINER ADDRESS (Street, City, State and Zip Code)

b. ROTC DETACHMENT CODE (If applicable):

MEASUREMENTS
11. HEIGHT (to nearest
1/4 inch)
STANDING SITTING

15. PULSE

12. BLOOD PRESSURE
SYSTOLIC DIASTOLIC

/

EXO

RH

1000

2000

3000

4000

6000

RIGHT

500

1000

2000

3000

4000

6000

UNSATISFACTORY
(Explain in Item 57)

LEFT
CYCLO

MANIFEST

18. REFRACTION

SATISFACTORY

BY LENS

19. NEAR VISION

RIGHT 20/

CORR TO 20/

SPH

CYL

AXIS

20/

CORR TO 20/

BY

LEFT 20/

CORR TO 20/

SPH

CYL

AXIS

20/

CORR TO 20/

BY

20. HETEROPHORIA/TROPIA
(Far only)
ESO

500

17. DISTANT VISION

16. WEIGHT (to
nearest pound)

14. READING ALOUD
TEST

13. AUDIOMETER

21. COVER TEST

LH

22. COLOR VISION
TEST USED

PASS
(Non-Tropia)

TEST USED

SCORE

PIP

No. Passed

No. Failed

VTA-ND/OVT/AFVT

FALANT

No. Passed

No. Failed

DPA-V

OTHER (Specify)

FAIL (Tropia)
24. NEAR POINT OF CONVERGENCE

23. DEPTH PERCEPTION
RESULTS

TITMUS/STEREO FLY
(Arcs per second)

25. VIVID RED/GREEN (If fail Item 22)
PASS

26. OCULAR MOTILITY AND BINOCULARITY (RED LENS TEST)

FAIL

PASS

FAIL

IF FAILED:

DIPLOPIA

SUPPRESSION

LABORATORY
27. URINALYSIS
PROTEIN

NEG

T

1+

2+

3+

4+

SUGAR

NEG

T

1+

2+

3+

4+

BLOOD

NEG

T

1+

2+

3+

4+

LEUKOCYTE
ESTERASE

NEG

T

1+

2+

3+

4+

MICROSCOPIC EXAMINATION (If required) (X one)
NEGATIVE
POSITIVE
(List results)

28. OTHER TESTS (Specify type and results)

DD FORM 2351, MAR 2004

PREVIOUS EDITION IS OBSOLETE.

Reset

DoD Exception to SF 88 Approved by GSA/OIRM 4-88

CLINICAL EVALUATION
NORMAL

(X each item in the appropriate column.
Enter "NE" if not evaluated)

ABNORMAL

(X each item in the appropriate column.
Enter "NE" if not evaluated)

NORMAL

29. HEAD, FACE, NECK AND SCALP

43. ABDOMEN AND VISCERA (Include hernia)

30. NOSE

44. ENDOCRINE SYSTEM

31. SINUSES

45. SPINE, OTHER MUSCULOSKELETAL

32. MOUTH AND THROAT

46. UPPER EXTREMITIES (Strength, sensation,
range of motion)

33. EARS - GENERAL(Internal and external canals)
(Auditory acuity under item 13)
34. DRUMS (Perforation)

47. LOWER EXTREMITIES (Except feet) (Strength,
sensation, range of motion)

35. VALSALVA

48. FEET

36. EYES - GENERAL (Visual acuity and refraction
under items 17, 18, and 19)

49. IDENTIFYING BODY MARKS, SCARS, TATTOOS

37. PUPILS (Equality and reaction)

51. GU SYSTEM

38. OCULAR MOTILITY (Associated parallel
movements, nystagmus)

52. ANUS AND RECTUM (Hemorrhoids, fistulae)
(Prostate if indicated) EXTERNAL EXAM

39. OPHTHALMOSCOPIC

53. FEMALE GU EXTERNAL VISUAL EXAM

40. LUNGS AND CHEST (Include breasts)

54. NEUROLOGIC

41. HEART (Thrust, size, rhythm, and sounds)

55. PSYCHIATRIC (Specify any personality deviation)

ABNORMAL

50. SKIN, LYMPHATICS

42. VASCULAR SYSTEM (Varicosities, etc.)
56. REPEAT BP OR PULSE EXAM (SITTING) IF BP >140/90 OR PULSE >100

57. NOTES (Describe every abnormality in detail. Enter the item number before each comment.)

58. EXAMINER (If performed by PA, PCNP, OR FNP)
TYPED OR PRINTED NAME

RANK

CORPS OR DEGREE

SIGNATURE

RANK

DEGREE

SIGNATURE

59. PHYSICIAN (MD/DO)
TYPED OR PRINTED NAME

DD FORM 2351 (BACK), MAR 2004

Reset