DD Form 2372 DoD Medical Examination Review Board (DoDMERB) Statement

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

DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)
STATEMENT OF PRESENT HEALTH

The public reporting burden for this collection of information is estimated to average 7 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. TYPED OR PRINTED NAME OF APPLICANT (Last, First, Middle Initial)

2. SSN OF APPLICANT

3. NAME OF PROGRAM(S) APPLYING FOR

4. STATEMENT OF PRESENT HEALTH

5. NAME OF MEDICATION(S) AND REASON FOR TAKING (If you are not taking any medications, state "NONE.")

6. REMARKS

INSTRUCTIONS
The Department of Defense Medical Examination Review Board (DODMERB) has been requested to update your Service Academy/ROTC
Medical Examination Report. Our records indicate that you were given a medical examination for last year's selection cycle. If there has been
no change in your medical or dental condition, we may be able to use your previous examination report as the basis for determining your
medical or dental status for the current selection cycle.
7. CERTIFICATION (Place an "X" in the appropriate block.)
I hereby certify that I have not received any medical or dental care since the date of my Service Academy/ROTC Medical Examination.
IS TRUE AND ACCURATE IN ALL REPORTS

IS NOT TOTALLY ACCURATE (Explain in detail below.)

DETAILED EXPLANATION WHY THE CERTIFICATION STATEMENT IS NOT TOTALLY ACCURATE (Attach additional pages if necessary.)

8. SIGNATURE OF APPLICANT

DD FORM 2372, MAR 2004

9. DATE SIGNED

PREVIOUS EDITION IS OBSOLETE.

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