DD Form 2370 DoD Medical Examination Review Board (DoDMERB) Three Day

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

DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)
THREE DAY BLOOD PRESSURE AND PULSE CHECK

The public reporting burden for this collection of information is estimated to average 90 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.
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 OF APPLICANT (Last, First, Middle Initial)

2. SSN OF APPLICANT

INSTRUCTIONS TO EXAMINERS
Studies have shown that the sphygmomanometer cuff must be the correct width for the circumference of the patient's arm. If it is too
narrow, the blood pressure readings will be erroneously high. If it is too wide, the readings may be erroneously low. For the average adult, a
cuff 12 to 14 cm wide is satisfactory. For arm circumference greater than 28 cm a larger cuff, 18 to 20 cm wide, must be used.
3. ARM CIRCUMFERENCE

4. WIDTH OF THE BLOOD
PRESSURE CUFF

5. MEDICATION CURRENTLY TAKEN (If none, so state.)

6. BLOOD PRESSURE AND PULSE READINGS
DAY ONE
DATE

A.M.

P.M.

BLOOD PRESSURE

PULSE

BLOOD PRESSURE

PULSE

SITTING MANDATORY
DAY TWO
DATE

A.M.

P.M.

BLOOD PRESSURE

PULSE

BLOOD PRESSURE

PULSE

SITTING MANDATORY
DAY THREE
DATE

A.M.

P.M.

BLOOD PRESSURE

PULSE

BLOOD PRESSURE

PULSE

SITTING MANDATORY
7. EXAMINER (Doctor/Nurse/Paramedical Technician)
TYPED OR PRINTED NAME (Last, First,
TITLE
Middle Initial)

DD FORM 2370, MAR 2004

PREVIOUS EDITION IS OBSOLETE.

SIGNATURE

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