DD Form 2492 DoD Medical Examination Review Board (DoDMERB) Report of

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

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

(This information is for official and medically confidential use only and will not be released to unauthorized persons.)

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 and Communications 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 (Last, First, Middle Initial)

3. TELEPHONE NO. (Include area code)

2. SOCIAL SECURITY NUMBER

5. EXAMINATION FACILITY OR EXAMINER AND ADDRESS (Include ZIP Code)

4. PURPOSE OF EXAMINATION

6. DATE OF EXAMINATION
(YYYYMMDD)

SECTION I
Mark each item "Yes" or "No". Every question must be answered. Every "Yes" must be explained in the REMARKS section. Mark and
explain each item to the best of your ability. Be perfectly honest! Your medical records may be requested to clarify your medical history.
7. HAVE YOU EVER OR DO
YOU NOW USE ANY OF
YES NO THE FOLLOWING:

YES

NO

NO

DO YOU

Marijuana

8. Wear glasses

Barbiturates

Alcohol (Amount,
frequency, treatment,
if any)

9. Wear contact lenses or
corneal eye retainers
(If Yes, complete 9a.)

Cocaine

Chemical Inhalants

Narcotic Drugs

Hallucinogens

Amphetamines

YES

YES

NO

HAVE YOU EVER HAD OR DO YOU NOW HAVE:

YES

9a. If you wear contact lenses, how many days have they
been removed prior to this examination?
Less than 3

3 - 20

21 or over

Type lens:

Hard

Soft

10. HAVE YOU EVER HAD YOUR VISION IMPROVED BY METHODS OTHER THAN STATED IN
QUESTIONS 8 OR 9?

NO

YES

NO

11. Eye trouble (exclude glasses, contact lenses)

40. Gallbladder trouble or gallstones

66. Sleepwalking episodes after age 12

12. Have fluctuating vision or double vision

41. Hepatitis (yellow jaundice)

67. Easily fatigued

13. Have any allergies

42. Hemorrhoids or rectal disease

68. Motion sickness (car, train, sea, or air)

14. Take any medications regularly

43. Black or bloody stools

69. X-ray or other radiation therapy

15. Stutter or stammer

44. Frequent or painful urination

70. Sensitivity to chemicals, dust, sunlight, etc.

16. Frequent, severe, or migraine headaches

45. Bed wetting after age 12

17. Fainting or dizzy spells

46. Blood, protein, or sugar in urine

18. Periods of unconsciousness

47. History of diabetes

19. Head injury or skull fracture

48. Kidney stone

20. Epilepsy, seizures or convulsions

49. Hernia or rupture

a. Inability to perform certain movements?

21. Loss of memory (amnesia)

50. Any bone or joint problem, injuries, surgery
or medical treatment

b. Inability to assume certain positions?

22. Depression, anxiety, excessive worry, or
nervousness

71. Learning disabilities or speech problems
YES

NO

HAVE YOU EVER
72. Been refused employment or been unable to
hold a job or stay in school because of:

c. Other medical reasons?

23. Any mental condition or illness

52. Wear a bone or joint brace or support

73. Been rejected for or discharged from military
service because of physical, mental or other
reasons?

24. Frequent trouble sleeping

53. Back pain or trouble

74. Been denied or rated up for life insurance?

25. Hearing loss

54. Paralysis or weakness

26. Ear, nose, or throat trouble

55. Foot trouble/use orthotics

75. Received or applied for pension or
compensation for existing disability?

27. Sinusitis or sinus trouble

56. Rheumatic fever

28. Hay fever or allergic rhinitis

57. Tuberculosis or positive TB test

29. Tooth/gum trouble, or current orthodontics

58. Sexually transmitted disease (syphilis,
gonorrhea, herpes)

77. Consulted, or been treated by clinics,
hospitals, physicians, healers, or other
practitioners for other than minor illnesses?

59. Skin conditions such as acne, psoriasis,
hand or foot rashes, eczema, or dry skin

78. Had any injury or illness other than those
already noted?

30. Thyroid trouble
31. Chronic cough or lung disease
32. Asthma or wheezing
33. Unusual shortness of breath

51. Steel pins, plates, or staples in any bones

76. Had or been advised to have, any surgical
operations?

YES

NO

FEMALES ONLY (Complete Items 79 - 82)

34. Pain or pressure in chest

60. Adverse reaction to vaccines, drugs,
medicines, foods, insect bites or stings

35. Palpitation or pounding heart

61. Eating disorder

79. Been treated for a female disorder, painful
periods, or cramps

36. Heart trouble or heart murmur

62. Recent gain or loss of weight

80. Had a change in menstrual pattern

37. High blood pressure

63. Excessive bleeding or easy bruising

81. Are you now pregnant?

38. Coughed up or vomited blood

64. Tumor, growth, cyst, or cancer

82. Date of last menstrual period (YYYYMMDD)

39. Stomach, liver, or intestinal trouble

DD FORM 2492, MAR 2004

65. Considered or attempted suicide

PREVIOUS EDITION IS OBSOLETE.

DoD Exception to SF93 approved by GSA/IRMS (8-91)

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SECTION II
83. REMARKS. Every "yes" response in items 7 through 81 must be explained in the space provided. Give specific dates and details
including names of physicians and hospitals or clinics and the current status of the condition. Continue on a separate sheet and attach
to this form if additional space is needed.

84. CERTIFICATION. I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my
knowledge. I authorize any of the physicians, hospitals, or clinics mentioned above to furnish the Government a complete transcript of my
medical record for purposes of processing my application for this employment or service.
TYPED OR PRINTED NAME OF EXAMINEE

DATE SIGNED
(YYYYMMDD)

SIGNATURE

NOTE: HAND TO THE PHYSICIAN OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL PERSONNEL ONLY."
85. EXAMINER'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Examiner shall comment on all "Yes" and blank answers (indicating the item
number before each comment). Develop by interview any additional medical history deemed important, and record significant findings here. If additional space is
needed, continue on a separate sheet and attach to this form.)

86. PHYSICIAN OR EXAMINER
TYPED OR PRINTED NAME

DD FORM 2492 (BACK), MAR 2004

SIGNATURE

DATE SIGNED
(YYYYMMDD)

87. NUMBER OF
ATTACHED
SHEETS

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