Form DD-2792 Exceptional Family Member Medical History

INSTRUCTIONS FOR COMPLETING DD FORM 2792,
EXCEPTIONAL FAMILY MEMBER MEDICAL SUMMARY

GENERAL.
The DD Form 2792 and attached addenda are
completed to identify a family member with special medical
needs.
The addenda to the medical summary are completed
only if noted in Item 8 of the Demographics/Certification
section (p.2).
The Exceptional Family Member Program (EFMP)/
Special Needs Identification and Clearance (SNIAC)
Screening Coordinator and the Parent/Guardian or Person
of Majority Age sign Items 6b and 9b only after all addenda
have been completed and the form reviewed for
completeness and accuracy.
AUTHORIZATION FOR DISCLOSURE (Page 1).
Health Insurance Portability and Accountability Act
(HIPAA) Requirement.
Each adult family member must sign for the release of
his/her own medical information. The sponsor or spouse
cannot authorize the release of information for those
dependent family members who have reached the age of
majority. Please consult with your military treatment
facility (MTF) or dental treatment facility (DTF)
privacy/HIPAA coordinator about questions regarding
authorizations for disclosure.
DEMOGRAPHICS/CERTIFICATION (Page 2).
Items 1 - 5 (Completed by Parent/Guardian or family
member who has reached the age of majority).
Item 1.a. Exceptional Family Member (EFM). Name of
family member described in subsequent pages.
Item 1.b. Applies to Military medical beneficiary only. The
Family Member Prefix is assigned when a family member
is enrolled in DEERS (see Item 4 below).
Items 1.c. - d. Self-explanatory.
Items 2.a. - k. All items refer to sponsor. Selfexplanatory.

Item 4. DEERS enrollment. If Yes, enter Social Security
Number and family member prefix for the DEERS enrollment.
Military only.
Item 5. Self-explanatory. If family member does not live with
sponsor, then enter the address where the family member does
live and explain why the family member does not live with
sponsor.
Item 6.a. - c. Parent/Guardian or Person of Majority Age.
Parent/guardian or person of majority age certifies that the
information contained in the DD 2792 is correct. Individual
must ensure that all forms are completed and attached
before signing.
Item 7. Application Status (X one).
Initial Screening Enrollment - First review of medical information
for the family member noted.
Updated Information - Update to a previous EFM evaluation for
the family member noted.
Request Disenrollment - Used to disenroll an EFM when he/she
no longer has the medical condition that required enrollment, or
when the EFM no longer qualifies as a dependent.
Item 7.b. Additional Family Member. X if there is another family
member who has been identified as an EFM.
Item 7.c. Indicate the number of other family members who have
been identified as an EFM. Do not include the individual
named in this application in the count of family members.
Item 8. Required Addenda. (Completed by provider and/or
EFMP/SNIAC Screening Coordinator.) Place an X next to each
addendum that requires completion based on a review of
medical records and/or screening of a family member. At this
time, also mark the appropriate response (Yes or No) at the
top of each addendum.
Items 9.a. - e. EFMP/SNIAC Screening Coordinator name,
signature, date, MTF address, telephone number. Selfexplanatory. Coordinator must ensure that all forms are
complete and attached before signing.
Item 9.f. This area is reserved for Service-specific guidance to
validate the form.

Item 3.a. Answer Yes if both spouses are on active duty;
otherwise answer No.
If Yes, complete Items 3.b. - e. All items refer to active
duty spouse. Self-explanatory.

DD FORM 2792 INSTRUCTIONS, 20060629 DRAFT

Page i
FormFlow/Adobe Professional 7.0

INSTRUCTIONS FOR COMPLETING DD FORM 2792 (Continued)

MEDICAL SUMMARY beginning on page 3 must be
completed by qualified medical professional.
Sponsor, spouse or family member of majority age must
sign release authorization on page 1 before the Summary
is completed.
Patient name, sponsor name, Family Member Prefix and Social
Security Number. Self-explanatory.

ADDENDUM 1 - ASTHMA/REACTIVE AIRWAY DISEASE
SUMMARY (p.6). To be completed by qualified medical
professional.
This addendum is completed only if indicated in Item 8,
page 2, Demographics/Certification, and may be completed by
a different provider than pages 3 - 5, if necessary.
Item 1. Self-explanatory.

Item 1.a. Diagnosis. Enter the diagnosis(es), one per line.
With the exception of asthma, cancer or mental health, identify
all diagnoses that have been active within the last year. For
asthma, cancer or mental health, identify all diagnoses active
within the past 5 years.
Item 1.b. Severity. Enter severity of the diagnosis(es) (A - mild,
B - moderate or C - severe).
Item 1.c. ICD or DSM. Enter ICD-9-CM or DSM IV
designations. REQUIRED.
Item 1.d. Medications and therapies. Self-explanatory.
Additional information may be included in item 9 if more space
is required.
Item 1.e. Enter per diagnosis the number of visits,
hospitalizations, etc., for the last 12 months.

Items 2.a.- d. Self-explanatory.

Item 2. Prognosis. Self-explanatory. Additional information
may be included in item 9 if more space is required.

This addendum is completed only if indicated in Item 8,
page 2, Demographics/Certification, and may be completed by
a different provider than pages 3 - 5, if necessary.

Item 3. Treatment Plan. Self-explanatory. Additional
information may be included in item 9 if more space is required.
Item 4. History of Cancer or Leukemia. Self-explanatory.

Items 3.a.- j. Self-explanatory.
Items 4.a. - f. Self-explanatory.
Items 5.a. - d. Self-explanatory.
Items 6.a. - f. Provider Information. Official Stamp or printed
name and signature of the provider completing this summary,
and date the summary was signed. Self-explanatory.
ADDENDUM 2 - MENTAL HEALTH SUMMARY
(pp. 7 - 8). To be completed by qualified clinical provider.

Item 1. Self-explanatory.
Items 2.a. - d. Self-explanatory. Item 2.c. ICD or DSM is
REQUIRED.

Item 5. Artificial Openings. Self-explanatory.
Item 3. Self-explanatory.
Item 6.a. Minimum Health Care Specialty. Codes in the first
column are used by Army coding teams only. Indicate with an
X those specialists essential (required) to meet the needs of
the patient. For example, if a developmental pediatrician is a
child's primary care provider, but a pediatrician can meet the
needs, do not mark developmental pediatrician.
Item 6.b. Frequency of care. Enter A - Annually; B - Biannually
(twice a year); Q - Quarterly; M - Monthly; or W - Weekly for
each specialist indicated.

Item 4. Prognosis. Self-explanatory. Additional information
may be included in Item 8 if more space is required.
Item 5. Treatment Plan. Self-explanatory. Additional
information may be included in Item 8 if more space is
required.
Item 6. Treatment needs within the next year. Mark only one
box considering all diagnoses. Self-explanatory.

Item 7. Environmental/Architectural Considerations.
Self-explanatory.

Items 7.a. - c. History. Self-explanatory.

Item 8. Adaptive Equipment/Special Medical Equipment.
Self-explanatory.

Item 8. Comments. Enter any additional information that would
assist in determining necessary treatment.

Item 9. Comments. Enter any additional information that would
assist in determining necessary treatment.

Item 9. Required Providers. Mark all providers who are
required to implement the treatment plan.

Items 10.a. - f. Provider Information. Official Stamp or printed
name and signature of the provider completing this summary,
and date the summary was signed. Self-explanatory.

Items 10.a - f. Provider Information. Official Stamp or printed
name and signature of the provider completing this summary,
and date the summary was signed. Self-explanatory.

DD FORM 2792 INSTRUCTIONS (BACK), 20060629 DRAFT

Page ii

EXCEPTIONAL FAMILY MEMBER MEDICAL SUMMARY
(To be completed by service member, adult family member, or civilian employee.)
(Read Instructions before completing this form.)

OMB No. 0704-0411
OMB approval expires

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 (0704-0411). 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.

PRIVACY ACT STATEMENT
AUTHORITY: 10 USC 3013, 5013, and 8013; 20 USC 921 - 932; and EO 9397.
PRINCIPAL PURPOSE(S): Information will only be used by personnel of the Department of Defense and Military Departments to evaluate and
document the medical needs of family members. This information will enable: (1) Military assignment personnel to match the needs of family
members against the availability of medical services and to engage in case management after assessment is made; (2) Civilian personnel offices to
determine the availability of medical services to meet the medical needs of family members of DoD and Military Department civilian employees; and
(3) Managed care support contractor to support your application for further entitlement, i.e., the Extended Care Health Option (ECHO).
ROUTINE USE(S): None.
DISCLOSURE: Voluntary for civilian employees and applicants for civilian employment; failure to respond will preclude the successful processing of
an application for family travel/command sponsorship.
Mandatory for military personnel; failure or refusal to provide the information or providing false information may result in administrative sanctions or
punishment under either Article 92 (dereliction of duty) or Article 107 (false official statement), Uniform Code of Military Justice.

AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION
By signing this authorization, you confirm you understand your sponsor will have access to the health information contained herein and in
addenda. The sponsor may be held accountable for the accuracy and completeness of the DD 2792 and addenda and should review all pages prior
to signing on page 2.
(MTF/DTF/Civilian Provider) (Name of Provider)

I authorize

to release my patient information to the Exceptional Family Member/Special Needs Program to be used in the enrollment and/or assignment
coordination process. The information on this form and addenda will be used to determine whether there are adequate medical, housing and
community resources to meet your special medical needs at the sponsor's proposed duty locations.
a. The military medical department will use the information to make recommendations on the availability of care in communities where the sponsor
may be assigned or employed.
b. Information that you have a special need (not the nature or scope of the need) may be included in the sponsor's personnel record or be
maintained in the community office responsible for supporting families with special needs.
c. The authorization applies to the summary data included on the medical summary form, its addenda and subsequent updates to information on
this form. These data may be stored in electronic databases used for medical management or dedicated to the assignment process. Only
representatives from the medical department and the offices responsible for EFMP assignment coordination will have access to the information.
Start Date: The authorization start date is the date that you sign this form authorizing release of information.
Expiration Date: The authorization shall continue until enrollment in the Exceptional Family Member Program/Special Needs Program is no longer
necessary according to criteria specified in DoD Instruction 1315.19, or if family member no longer meets the criteria to qualify as a dependent, or
the sponsor is no longer in active military service or employment of the U.S. Government overseas.
I understand that:
a. I have the right to revoke this authorization at any time. My revocation must be in writing and provided to the facility where my or my child's
medical records are kept. I am aware that if I later revoke this authorization, the person(s) I herein name will have used and/or disclosed protected
information on the basis of this authorization. My revocation will have no impact on disclosures made prior to the revocation.
b. If I authorize my or my child's protected health information to be disclosed to someone who is not required to comply with federal privacy
protection regulations, then such information may be re-disclosed and would no longer be protected.
c. I have a right to inspect and receive a copy of my own or my child's protected health information to be used or disclosed, in accordance with the
requirements of the federal privacy protection regulations found in the Privacy Act and 45 CFR 164.524. I request and authorize the named
provider/treatment facility to release the information described above for the stated purposes.
d. The Military Health System (which includes the TRICARE Health Plan) may not condition treatment in MTFs/DTFs, payment by the TRICARE
Health Plan, enrollment in the TRICARE Health Plan or eligibility for TRICARE Health Plan benefits on failure to obtain this authorization.
e. Refusal to sign does not preclude the provision of medical and dental information authorized by other regulations and those noted in this
document.
NAME OF PATIENT

SIGNATURE OF PATIENT/PARENT/GUARDIAN

RELATIONSHIP TO PATIENT

DATE (YYYYMMDD)

(If applicable)

DD FORM 2792, 20060629 DRAFT

PREVIOUS EDITION IS OBSOLETE.

Page 1 of 8 Pages

DEMOGRAPHICS/CERTIFICATION: To be completed by the Sponsor, Parent or Guardian, or Patient
1.a. EXCEPTIONAL FAMILY MEMBER NAME (Last, First, Middle Initial)

b. FAMILY MEMBER PREFIX
(FMP)

c. GENDER (X)
MALE

d. DATE OF BIRTH
(YYYYMMDD)

FEMALE

2.a. SPONSOR NAME (Last, First, Middle Initial)

b. SPONSOR SSN

d. BRANCH OF SERVICE (Military only)

e. DESIGNATION/NEC/MOS/AFSC (Military only)

f. CURRENT ADDRESS (Street, Apartment Number, City, State, ZIP Code)

g. DUTY STATION ADDRESS

c. RANK OR GRADE

h. OFFICIAL E-MAIL ADDRESS

i. CURRENT TELEPHONE NUMBER
(Include Area Code)

j. FAX NUMBER
(Include Area Code)

k. DUTY TELEPHONE NUMBER (Include Area Code)
(1) COMMERCIAL

(2) DSN

3.a. ARE BOTH SPOUSES ON ACTIVE DUTY? (Military only) (X one. If Yes, complete 3.b. - e. below)
b. ACTIVE DUTY SPOUSE'S NAME (Last, First, Middle Initial) c. BRANCH OF SERVICE

YES

d. RANK/RATE

NO

e. SPOUSE SSN

4. IS FAMILY MEMBER ENROLLED IN DEERS (Military only) (X one)
YES

NO

IF YES, UNDER WHAT SSN:

FAMILY MEMBER PREFIX:

5. DOES FAMILY MEMBER RESIDE WITH SPONSOR (X one)
YES
NO. IF NO, PROVIDE ADDRESS OF FAMILY MEMBER (Include ZIP Code) AND EXPLAIN WHY.

STOP.
6. CERTIFICATION.
DO NOT CERTIFY BEFORE COMPLETING ENTIRE FORM AND ADDENDA.
By signing below, we certify that the information submitted on this DD Form 2792 (Medical Summary and the addenda checked below) is complete
and accurate.
PARENT/GUARDIAN OR PERSON OF MAJORITY AGE:
a. PRINTED NAME

b. SIGNATURE

c. DATE (YYYYMMDD)

FOR OFFICIAL USE ONLY
7.a. APPLICATION STATUS (X one)
INITIAL SCREENING

UPDATED INFORMATION

REQUEST DISENROLLMENT
YES

b. ARE THERE OTHER EFMP MEMBERS IN THE FAMILY?

NO

c. IF YES, HOW MANY?

8. REQUIRED ADDENDA. Complete Item 1 on Addendum 1 (page 6) and item 1 on Addendum 2 (page 7) AND X box below if:
ASTHMA ADDENDUM 1 IS REQUIRED
MENTAL HEALTH SUMMARY ADDENDUM 2 IS REQUIRED
DD FORM 2792-1, "EXCEPTIONAL FAMILY MEMBER SPECIAL EDUCATION/EARLY INTERVENTION SUMMARY" IS REQUIRED

9. EFMP/SNIAC SCREENING COORDINATOR
a. PRINTED NAME

b. SIGNATURE

d. MILITARY TREATMENT FACILITY ADDRESS (Include ZIP Code)

DD FORM 2792, 20060629 DRAFT

c. DATE (YYYYMMDD)

e. TELEPHONE NUMBER
(Include area code)

f. OFFICIAL STAMP

Page 2 of 8 Pages

PATIENT NAME

SPONSOR NAME

SPONSOR SSN

FAMILY MEMBER PREFIX

MEDICAL SUMMARY: To be completed by a Qualified Medical Professional
PART A - PATIENT STATUS
1. DIAGNOSIS(ES)

Please complete as accurately as possible using ICD-9-CM or DSM IV.

a.
ACTIVE DIAGNOSIS WITHIN LAST
YEAR (If Asthma, Cancer or Mental
Health within last 5 years)

b.
c.
SEVERITY:
ICD
A - Mild
OR DSM
B - Moderate
REQUIRED
C - Severe

d.
MEDICATIONS AND
SPECIAL THERAPIES

e.
COMPLETE FOR
THE LAST 12 MONTHS:

If Asthma or RAD is noted, also complete Asthma Addendum 1.
If Mental Health is noted, also complete Mental Health Addendum 2.
(1) NUMBER OF OUTPATIENT VISITS
(2) NUMBER OF ER VISITS
(3) NUMBER OF HOSPITALIZATIONS
(4) NUMBER OF ICU ADMISSIONS
(1) NUMBER OF OUTPATIENT VISITS
(2) NUMBER OF ER VISITS
(3) NUMBER OF HOSPITALIZATIONS
(4) NUMBER OF ICU ADMISSIONS
(1) NUMBER OF OUTPATIENT VISITS
(2) NUMBER OF ER VISITS
(3) NUMBER OF HOSPITALIZATIONS
(4) NUMBER OF ICU ADMISSIONS
(1) NUMBER OF OUTPATIENT VISITS
(2) NUMBER OF ER VISITS
(3) NUMBER OF HOSPITALIZATIONS
(4) NUMBER OF ICU ADMISSIONS
(1) NUMBER OF OUTPATIENT VISITS
(2) NUMBER OF ER VISITS
(3) NUMBER OF HOSPITALIZATIONS
(4) NUMBER OF ICU ADMISSIONS
(1) NUMBER OF OUTPATIENT VISITS
(2) NUMBER OF ER VISITS
(3) NUMBER OF HOSPITALIZATIONS
(4) NUMBER OF ICU ADMISSIONS
(1) NUMBER OF OUTPATIENT VISITS
(2) NUMBER OF ER VISITS
(3) NUMBER OF HOSPITALIZATIONS
(4) NUMBER OF ICU ADMISSIONS

2. PROGNOSIS (Include expected length of treatment, required participation of family members, and if treatment is ongoing)

3. TREATMENT PLAN (Medical, mental health, surgical procedures or therapies planned over the next three years)

4. HISTORY OF CANCER OR LEUKEMIA
YES

(If Yes, specify projected treatment needs)

NO

5. ARTIFICIAL OPENINGS/PROSTHETICS (X all that apply)
YES
NO

IF YES:

F01 - GASTROSTOMY

F05 - COLOSTOMY

F02 - TRACHEOSTOMY

F06 - ILEOSTOMY

F03 - CSF SHUNT

F07 - OTHER UNSPECIFIED PROSTHETICS (Specify)

F04 - CYSTOSTOMY

F99 - OTHER UNSPECIFIED OPENING (Specify)

DD FORM 2792, 20060629 DRAFT

Page 3 of 8 Pages

PATIENT NAME

SPONSOR NAME

SPONSOR SSN

FAMILY MEMBER PREFIX

MEDICAL SUMMARY (Continued): To be completed by a Qualified Medical Professional
PART B - REQUIRED CARE
6. MINIMUM HEALTH CARE SPECIALTY REQUIRED FOR CARE
INDICATE THE FREQUENCY OF CARE:

A - ANNUALLY

(1) CARE PROVIDER
(X as appropriate)

B - BIANNUALLY (Twice a year)
(2)
FREQUENCY
(See above)

Q - QUARTERLY

M - MONTHLY

W - WEEKLY
(2)
FREQUENCY
(See above)

(1) CARE PROVIDER
(X as appropriate)

C01

a. ALLERGIST/IMMUNOLOGIST

C47

gg. ORTHOPEDIC SURGEON - ADULT

C52

b. AUDIOLOGIST

C48

hh. ORTHOPEDIC SURGEON - PEDIATRIC

C42

c. CARDIAC/THORACIC SURGEON

C57

ii.

PAIN CLINIC

C02

d. CARDIOLOGIST - ADULT

C30

jj.

PEDIATRICIAN

C03

e. CARDIOLOGIST - PEDIATRIC

C49

kk. PEDIATRIC SURGEON

C05

f.

C32

ll.

C06

g. DEVELOPMENTAL PEDIATRICIAN

C58

mm. PHYSICAL THERAPIST

C53

h. DIALYSIS TEAM

C50

nn. PLASTIC SURGEON

C07

i.

DIETARY/NUTRITION SPECIALIST

C35

oo. PSYCHIATRIST - ADULT

C08

j.

ENDOCRINOLOGIST - ADULT

C36

pp. PSYCHIATRIST - PEDIATRIC

C09

k. ENDOCRINOLOGIST - PEDIATRIC

C37

qq. PSYCHOLOGIST - ADULT

C10

l.

C38

rr.

PSYCHOLOGIST - PEDIATRIC

C11

m. GASTROENTEROLOGIST - ADULT

C33

ss.

PULMONOLOGIST - ADULT

C12

n. GASTROENTEROLOGIST - PEDIATRIC

C99

tt.

C43

o. GENERAL SURGEON

C60

uu. RESPIRATORY THERAPIST

C14

p. GENETICS

C39

vv.

C15

q. GYNECOLOGIST

C40

ww. RHEUMATOLOGIST - PEDIATRIC

C17

r. HEMATOLOGIST/ONCOLOGIST - ADULT

C61

xx.

SOCIAL WORKER

C18

s. HEMATOLOGIST/ONCOLOGIST - PEDIATRIC

C62

yy.

SPEECH AND LANGUAGE PATHOLOGIST

C99

t.

C41

zz.

TRANSPLANT TEAM

C20

u. INTERNIST

C51

aaa. UROLOGIST

C21

v.

C99

bbb. OTHER (Describe)

C22

w. NEPHROLOGIST - PEDIATRIC

C23

x. NEUROLOGIST - ADULT

C24

y. NEUROLOGIST - PEDIATRIC

C44

z. NEUROSURGEON

C54

aa. OCCUPATIONAL THERAPIST - ADULT

C55

bb. OCCUPATIONAL THERAPIST - PEDIATRIC

C26

cc. OPHTHALMOLOGIST - ADULT

C27

dd. OPHTHALMOLOGIST - PEDIATRIC

C57

ee. ORAL SURGEON

C56

ff. OTORHINOLARYNGOLOGIST

DERMATOLOGIST

FAMILY PRACTITIONER

INFECTIOUS DISEASE

NEPHROLOGIST - ADULT

DD FORM 2792, 20060629 DRAFT

PHYSIATRIST (Physical Rehabilitation)

PULMONOLOGIST - PEDIATRIC

RHEUMATOLOGIST - ADULT

Page 4 of 8 Pages

PATIENT NAME

SPONSOR NAME

SPONSOR SSN

FAMILY MEMBER PREFIX

MEDICAL SUMMARY (Continued): To be completed by a Qualified Medical Professional
7. ENVIRONMENTAL/ARCHITECTURAL CONSIDERATIONS
LIMITED STEPS (If Yes, please explain)
COMPLETE WHEELCHAIR ACCESSIBILITY
AIR CONDITIONING (If Yes, please explain)
OTHER (Specify)

8. ADAPTIVE EQUIPMENT/SPECIAL MEDICAL EQUIPMENT
L03 - APNEA HOME MONITOR

L99 - OTHER (Specify)

L13 - HOME NEBULIZER
L08 - WHEELCHAIR
L07 - SPLINTS, BRACES, ORTHOTICS
L04 - HEARING AIDS
L12 - HOME OXYGEN THERAPY
L14 - HOME VENTILATOR
L99 - HOME DIALYSIS MACHINE

9. COMMENTS (Enter additional information to describe this individual's medical needs.)

PART C - PROVIDER INFORMATION (Authorization by patient included on Page 1 of this form.)
10.a. PROVIDER PRINTED NAME OR STAMP

b. SIGNATURE

d. TELEPHONE NUMBERS (Include Area Code)
(1) COMMERCIAL

(2) DSN (Military only)

c. DATE (YYYYMMDD)

e. MAILING ADDRESS (Include ZIP Code)
(3) FAX NUMBER

f. OFFICIAL E-MAIL ADDRESS

DD FORM 2792, 20060629 DRAFT

Page 5 of 8 Pages

PATIENT NAME

SPONSOR NAME

SPONSOR SSN

FAMILY MEMBER PREFIX

ADDENDUM 1 - ASTHMA/REACTIVE AIRWAY DISEASE SUMMARY: To be completed by a Qualified Medical Professional
1. PATIENT HAS BEEN EVALUATED OR TREATED FOR ASTHMA WITHIN THE PAST 5 YEARS.
NO

YES

IF YES, CONTINUE COMPLETION OF ASTHMA ADDENDUM ITEMS 2 - 6.

2. MEDICATION HISTORY
a. MEDICATION

b. DOSAGE

c. FREQUENCY

d. APPROXIMATE DATE
MEDICATION LAST USED

3. HISTORY ASSOCIATED WITH ASTHMA ATTACKS (X as applicable)
YES

NO
a. ARE THERE ANY TRIGGERS FOR THE FAMILY MEMBER'S ASTHMA ATTACKS (stress, environment, exercise)?
b. DOES THE FAMILY MEMBER ROUTINELY (greater than 10 days per month/four months per year) USE INHALED ANTI-INFLAMMATORY
AGENTS AND/OR BRONCHODILATORS?
c. HAS THE FAMILY MEMBER TAKEN ORAL STEROIDS DURING THE PAST YEAR (prednisone, prednisolone)?
IF YES, NUMBER OF DAYS IN PAST YEAR:
d. HAS THE FAMILY MEMBER EVER EXPERIENCED UNCONSCIOUSNESS OR SEIZURES ASSOCIATED WITH ASTHMA ATTACKS?
e. HAS THE FAMILY MEMBER REQUIRED AN URGENT VISIT TO THE ER OR CLINIC FOR ACUTE ASTHMA DURING THE PAST YEAR?
IF "YES', INDICATE THE NUMBER OF VISITS IN THE PAST YEAR:
f. HAS THE FAMILY MEMBER BEEN HOSPITALIZED FOR PULMONARY DISEASE (pneumonia, bronchitis, bronchiolitis, croup, RSV) DURING
THE PAST YEAR? IF "YES', INDICATE THE DATE(S) OF HOSPITALIZATION (YYYYMMDD):
g. DOES THE FAMILY MEMBER HAVE A HISTORY OF ONE OR MORE HOSPITALIZATIONS FOR ASTHMA RELATED CONDITIONS WITHIN
THE PAST 5 YEARS? IF "YES', HOW MANY?
INDICATE DATE OF LAST ADMISSION (YYYYMMDD):
h. HAS THE FAMILY MEMBER REQUIRED MECHANICAL VENTILATION (Intubation/use of respirator) DURING THE PAST 3 YEARS?
i. DOES THE FAMILY MEMBER HAVE A HISTORY OF INTENSIVE CARE ADMISSIONS?

j. HOW MANY DAYS HAS THE FAMILY MEMBER MISSED SCHOOL/WORK/PLAY DUE TO ASTHMA-RELATED PROBLEMS (including visits to physicians)
DURING THE PAST YEAR?

4. DISRUPTION OF ACTIVITY. How often does asthma disrupt the following activities? (X as applicable)
(1) ACTIVITY

(2) NEVER A
PROBLEM

(3) 2 TIMES A
(4) 3 - 7
(5) 8 - 10 TIMES (6) AT LEAST
YEAR OR LESS TIMES A YEAR
A YEAR
MONTHLY

(7) AT LEAST
WEEKLY

(8) ALMOST
DAILY

a. SLEEP
b. QUIET ACTIVITY
c. SOCIALIZING WITH FRIENDS
d. SCHOOL OR WORK ATTENDANCE
e. OUTDOOR ACTIVITIES
f. VIGOROUS/PLAY ACTIVITIES

5. SEVERITY LEVEL. What is the family member's severity level based on the clinical picture? (Select one level of severity.
Definitions are examples of severity. Pulmonary function tests are required only if clinically indicated.)
a. INTERMITTENT ASTHMA. Intermittent symptoms < 1 time per week. Brief exacerbations (from a few hours to a few days). Nighttime asthma
symptoms < 2 times a month. Asymptomatic and normal lung function between exacerbations. PEF or FEV1 > 80% predicted; variability <20%.
b. MILD PERSISTENT ASTHMA. Symptoms > 2 times a week but < 1 time per day. Exacerbations may affect sleep and activity. Nighttime asthma
symptoms > 2 times a month. PEF or FEV1 > 80% predicted; variability 20 - 30%.
c. MODERATE PERSISTENT. Symptoms daily. Exacerbations affect sleep and activity. Nighttime asthma > 1 time a week. Daily use of inhaled
short-acting B2 agonist. PEF or FEV1 > 60% and 80% predicted; variability > 30%.
d. SEVERE PERSISTENT. Continuous symptoms. Frequent exacerbations. Frequent nighttime asthma symptoms. Physical activities limited by asthma
symptoms. PEF or FEV1 < 60% predicted; variability > 30%.

6.a. PROVIDER PRINTED NAME OR STAMP

b. SIGNATURE

d. TELEPHONE NUMBERS (Include Area Code)
(1) COMMERCIAL

(2) DSN (Military only)

c. DATE (YYYYMMDD)

e. MAILING ADDRESS (Include ZIP Code)
(3) FAX NUMBER

f. OFFICIAL E-MAIL ADDRESS

DD FORM 2792 (ADDENDUM 1), 20060629 DRAFT

Page 6 of 8 Pages

PATIENT NAME

SPONSOR NAME

SPONSOR SSN

FAMILY MEMBER PREFIX

ADDENDUM 2 - MENTAL HEALTH SUMMARY: To be Completed by a Qualified Clinical Provider
1. PATIENT HAS CURRENT OR PAST (within the last 5 years) HISTORY OF MENTAL HEALTH DIAGNOSIS
NO

YES

IF YES, CONTINUE WITH COMPLETION OF MENTAL HEALTH ADDENDUM.

2. DIAGNOSIS(ES) Please complete as accurately as possible using ICD-9-CM or DSM IV.
a.
DIAGNOSIS (Currently or experienced within last 5 years)

b.
SEVERITY:
A - Mild
B - Moderate
C - Severe

c.
ICD
OR DSM
REQUIRED

d.
AGE AT
DIAGNOSIS

3. HISTORY OF MEDICATIONS AND THERAPIES RECEIVED OR RECOMMENDED AND FREQUENCY

4. PROGNOSIS (Include past compliance with treatment programs, expected length of treatment, required participation of family members, and if
treatment is ongoing.)

5. TREATMENT PLAN (Medical, mental health, surgical procedures or therapies related to the patient's mental health condition planned over the
next three years)

6. TREATMENT NEEDS WITHIN THE NEXT YEAR (Consider increased stressors of residing in new environment (e.g.,stressors of family
relocation, isolated posts, deployments, foreign cultures, restricted travel, separation from nuclear family, cost of living.)
NO ASSISTANCE REQUIRED

FEWER THAN 4 CONTACTS

DD FORM 2792 (ADDENDUM 2), 20060629 DRAFT

4 OR MORE CONTACTS

INPATIENT SERVICES

Page 7 of 8 Pages

PATIENT NAME

SPONSOR NAME

SPONSOR SSN

FAMILY MEMBER PREFIX

ADDENDUM 2 - MENTAL HEALTH SUMMARY (Continued): To be Completed by a Qualified Clinical Provider
8. HISTORY
YES

NO
a. HISTORY OF SUICIDAL GESTURES/ATTEMPTS?
b. HISTORY OF SUBSTANCE ABUSE/ADDICTIVE BEHAVIORS/EATING DISORDERS/OTHER COMPULSIVE BEHAVIORS?
c. HISTORY OF PROBLEMS WITH LEGAL AUTHORITY? (If Yes, specify)

d. HISTORY OF PSYCHOTIC EPISODES?
e. HISTORY OF SERVICES RECEIVED FOR ALLEGATIONS OF FAMILY MALTREATMENT? (If Yes, and services are delivered by Family Advocacy,
note case determination.)

8. OTHER COMMENTS (Include additional information that would assist in determining necessary treatments.)

9. PROVIDERS REQUIRED TO IMPLEMENT TREATMENT PLAN
PSYCHIATRIST

PSYCHOLOGIST

SOCIAL WORKER

OTHER (Specify)

10. PROVIDER INFORMATION (Authorization by patient included on Page 1 of this form.)
a. PRINTED NAME OR STAMP

b. SIGNATURE

d. TELEPHONE NUMBERS (Include Area Code)
(1) COMMERCIAL

(2) DSN (Military only)

c. DATE (YYYYMMDD)

e. MAILING ADDRESS (Include ZIP Code)
(3) FAX NUMBER

f. OFFICIAL E-MAIL ADDRESS

DD FORM 2792 (ADDENDUM 2) (BACK), 20060629 DRAFT

Page 8 of 8 Pages