DD Form 2374 DoD Medical Examination Review Board (DoDMERB) Heart Mur

DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)
HEART MURMUR EVALUATION

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

The public reporting burden for this collection of information is estimated to average 30 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 EXAMINER
Conditions such as mitral valve prolapse and bicuspid aortic valve are being found even in the presence of "innocent" or "functional"
murmurs. We request that you complete this form which will enable the Department of Defense Medical Examination Review Board to make a
proper determination of the applicant's cardiac status. Echocardiogram is mandatory unless auscultation is negative.
3. GRADE, AMPLITUDE OR INTENSITY (Use the I - VI Scale)

4. LOCATION (Where is the sound heard best?)

5. TIMING DURING THE CARDIAC CYCLE (e.g., mid-systole)

6. CHARACTER OF THE SOUND (e.g., crescendo - decrescendo)

7. RADIATION OR TRANSMISSION OF THE SOUND

8. OTHER SOUNDS (e.g., click)

9. RESULT OF ECHOCARDIOGRAM (Please attach results - NOT TRACINGS.)

10. FINAL IMPRESSION AND OTHER COMMENTS

11. EXAMINING PHYSICIAN
TYPED OR PRINTED NAME (Last, First, Middle
Initial)

DD FORM 2374, MAR 2004

SIGNATURE

PREVIOUS EDITION IS OBSOLETE.

DATE SIGNED

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