Form DD Form 2807-1 DD Form 2807-1 Report of Medical History

REPORT OF MEDICAL HISTORY

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

OMB No. 0704-0413
OMB approval expires

The public reporting burden for this collection of information is estimated to average 10 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 the burden estimate or burden reduction suggestions to the Department of
Defense, Washington Headquarters Services, at [email protected]. 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 AS INDICATED ON PAGE 2.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 136, Under Secretary Of Defense For Personnel And Readiness; DoD Directive 1145.2, United States Military Entrance Processing Command; DoD Instruction 6130.03,
Medical Standards for Appointment, Enlistment, or Induction in the Military Services; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): The primary collection of this information is from individuals seeking to join the Armed Forces. The information collected on this form is used to assist DoD physicians in
making determinations as to acceptability of applicants for military service and verifies disqualifying medical condition(s) noted on the prescreening form (DD 2807-2). An additional collection of
information using this form occurs when a Medical Evaluation Board is convened to determine the medical fitness of a current member and if separation is warranted.
ROUTINE USE(S): The Routine Uses are listed in the applicable system of records notice found at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570661/
a0601-270-usmepcom-dod/
DISCLOSURE: Voluntary; however, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application to enter the Armed Forces. An applicant's
SSN is used during the recruitment process to keep all records together and when requesting civilian medical records. For an Armed Forces member, failure to provide the information may result in the
individual being placed in a non-deployable status. The SSN of an Armed Forces member is to ensure the collected information is filed in the proper individual's record.

WARNING: The information you have given constitutes an official statement. Federal law provides severe penalties (up to 5 years confinement or a
$10,000 fine or both), to anyone making a false statement.
1. LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX)

2.a. SOCIAL SECURITY NO.

4.a. HOME ADDRESS (Street, Apartment No., City, State, and ZIP Code)

5. EXAMINING LOCATION AND ADDRESS (Include ZIP Code)

b. HOME TELEPHONE (Include Area Code)
c. EMAIL ADDRESS

N E E D S

D D

Army
Navy

Coast
Guard

b. COMPONENT

Marine Corps

3. TODAY'S DATE
(YYYYMMDD)

6 7

7.a. POSITION (Title, Grade, Component)

X ALL APPLICABLE BOXES:
6.a. SERVICE

b. DoD ID NO. (If applicable)

c. PURPOSE OF EXAMINATION

Regular

Retention

Reserve

Separation

National Guard

Medical Board

Retirement
Air Force
8. CURRENT MEDICATIONS (Prescription and Over-the-counter)

Other (Specify)
b. USUAL OCCUPATION

9. ALLERGIES (Including insect bites/stings, foods, medicine or other substance)

Mark each item "YES" or "NO". Every item marked "YES" must be fully explained in Item 29 on Page 2.
HAVE YOU EVER HAD OR DO YOU NOW HAVE:

YES NO

12. (Continued)

b. Lived with someone who had tuberculosis

g. Impaired use of arms, legs, hands, or feet

c. Coughed up blood
d. Asthma or any breathing problems related to exercise, weather,

h. Swollen or painful joint(s)
i. Knee trouble (e.g., locking, giving out, pain or ligament injury, etc.)
j. Any knee or foot surgery including arthroscopy or the use of a scope

pollens, etc.

e. Shortness of breath

to any bone or joint

f. Bronchitis

k. Any need to use corrective devices such as prosthetic devices, knee

g. Wheezing or problems with wheezing

l. Bone, joint, or other deformity

brace(s), back support(s), lifts or orthotics, etc.

h. Been prescribed or used an inhaler

m. Plate(s), screw(s), rod(s) or pin(s) in any bone

i. A chronic cough or cough at night

n. Broken bone(s) (cracked or fractured)

j. Sinusitis

13.a. Frequent indigestion or heartburn

k. Hay fever

b. Stomach, liver, intestinal trouble, or ulcer

l. Chronic or frequent colds

c. Gall bladder trouble or gallstones
d. Jaundice or hepatitis (liver disease)

11.a. Severe tooth or gum trouble
b. Thyroid trouble or goiter

e. Rupture/hernia

c. Eye disorder or trouble

f. Rectal disease, hemorrhoids or blood from the rectum

d. Ear, nose, or throat trouble

g. Skin diseases (e.g. acne, eczema, psoriasis, etc.)

e. Loss of vision in either eye

h. Frequent or painful urination

f. Worn contact lenses or glasses

i. High or low blood sugar

g. A hearing loss or wear a hearing aid

j. Kidney stone or blood in urine

h. Surgery to correct vision (RK, PRK, LASIK, etc.)

k. Sugar or protein in urine
l. Sexually transmitted disease (syphilis, gonorrhea, chlamydia, genital

12.a. Painful shoulder, elbow or wrist (e.g. pain, dislocation, etc.)
b. Arthritis, rheumatism, or bursitis

YES NO

f. Foot trouble (e.g., pain, corns, bunions, etc.)

10.a. Tuberculosis

warts, herpes, etc.)

14.a. Adverse reaction to serum, food, insect stings or medicine

c. Recurrent back pain or any back problem

b. Recent unexplained gain or loss of weight

d. Numbness or tingling

c. Currently in good health (If no, explain in Item 29 on Page 2.)

e. Loss of finger or toe

DD FORM 2807-1, 20171017 DRAFT

d. Tumor, growth, cyst, or cancer
DoD exception to SF 93 approved by ICMR, August 3, 2000.

PREVIOUS EDITION IS OBSOLETE.

Page 1 of 3 Pages

Adobe Professional XI

LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX)

SOCIAL SECURITY NUMBER

DoD ID NUMBER (If applicable)

Mark each item "YES" or "NO". Every item marked "YES" must be fully explained in Item 29 below.
HAVE YOU EVER HAD OR DO YOU NOW HAVE:
YES NO
15.a. Dizziness or fainting spells
b. Frequent or severe headache

YES NO

19. Have you been refused employment or been unable to hold a job
or stay in school because of:

c. A head injury, memory loss or amnesia

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

d. Paralysis

b. Inability to perform certain motions

e. Seizures, convulsions, epilepsy or fits

c. Inability to stand, sit, kneel, lie down, etc.

f. Car, train, sea, or air sickness

d. Other medical reasons (If yes, give reasons.)

g. A period of unconsciousness or concussion
h. Meningitis, encephalitis, or other neurological problems
16.a. Rheumatic fever
b. Prolonged bleeding (as after an injury or tooth extraction, etc.)
c. Pain or pressure in the chest
d. Palpitation, pounding heart or abnormal heartbeat
e. Heart trouble or murmur
f. High or low blood pressure
17.a. Nervous trouble of any sort (anxiety or panic attacks)
b. Habitual stammering or stuttering
c. Loss of memory or amnesia, or neurological symptoms

N E E D S

d. Frequent trouble sleeping

e. Received counseling of any type
f. Depression or excessive worry

g. Been evaluated or treated for a mental condition
h. Attempted suicide
i. Used illegal drugs or abused prescription drugs

18. FEMALES ONLY. Have you ever had or do you now have:
a. Treatment for a gynecological (female) disorder
b. A change of menstrual pattern

20. Have you ever been treated in an Emergency Room?
(If yes, for what?)
21. Have you ever been a patient in any type of hospital? (If yes,
specify when, where, why, and name of doctor and complete
address of hospital.)
22. Have you ever had, or have you been advised to have any
operations or surgery? (If yes, describe and give age at which
occurred.)
23. Have you ever had any illness or injury other than those
already noted? (If yes, specify when, where, and give details.)
24. Have you consulted or been treated by clinics, physicians,
healers, or other practitioners within the past 5 years for
other than minor illnesses? (If yes, give complete address
of doctor, hospital, clinic, and details.)

D D

6 7

25. Have you ever been rejected for military service for any
reason? (If yes, give date and reason for rejection.)

26. Have you ever been discharged from military service for any
reason? (If yes, give date, reason, and type of discharge;
whether honorable, other than honorable, for unfitness or
unsuitability.)

d. First day of last menstrual period (YYYYMMDD)

27. Have you ever received, is there pending, or have you ever
applied for pension or compensation for any disability
or injury? (If yes, specify what kind, granted by whom,
and what amount, when, why.)

e. Date of last PAP smear (YYYYMMDD)

28. Have you ever been denied life insurance?

c. Any abnormal PAP smears

29. EXPLANATION OF "YES" ANSWER(S) (Describe answer(s), give date(s) of problem, name of doctor(s) and/or hospital(s), treatment given and current medical
status.)

NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL PERSONNEL ONLY."

DD FORM 2807-1, 20171017 DRAFT

Page 2 of 3 Pages

LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX)

SOCIAL SECURITY NUMBER

DoD ID NUMBER (If applicable)

30. EXAMINER'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician/practitioner shall comment on all positive answers in
questions 10 - 29. Physician/practitioner may develop by interview any additional medical history deemed important, and record any
significant findings here.)
a. COMMENTS

N E E D S

b. TYPED OR PRINTED NAME OF EXAMINER (Last, First, Middle Initial)

DD FORM 2807-1, 20171017 DRAFT

D D

c. SIGNATURE

6 7

d. DATE SIGNED
(YYYYMMDD)

Page 3 of 3 Pages