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

CUI (when filled in)
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
20241031

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 reaction suggestions to the Department of Defense, Washington Headquarter 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; 10 U.S.C. Subtitle A, General Military Law, Part II, Personnel (Chapter 31, Enlistments and Chapter 33, Original Appointments of Regular
Officers in Grades Above Warrant Officer Grades); 10 U.S.C. 3013, Secretary of the Army; 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 8013, Secretary of the Air Force; DoD Directive (DoDD) 1145.02E, United States
Military Entrance Processing Command (USMEPCOM); DoD Instruction (DoDI) 1304.02, Accession Processing Data Collection Forms; DoDI 1304.12E, DoD Military Personnel Accession Testing Programs; DoDI 1304.26,
Qualification Standards for Enlistment, Appointment and Induction; DoDI 1332.18, Disability Evaluation System; DoDI 6130.03, Medical Standards for Appointment, Enlistment, or Induction in the Military Services; DoD Manual
1145.02, Military Entrance Processing Station (MEPS); USMEPCOM Regulation 680-3, Entrance Processing and Reporting System Management; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To assist DoD physicians in making determinations as to acceptability of applicants for military service and to verify disqualify medical condition(s) noted on the accessions medical history report
(DD2807-2). This form may also be used by Medical Evaluation Boards to determine the medical fitness of a current member and if separation is warranted.
ROUTINE USE(S): Disclosure of records are generally permitted under 5 U.S.C. 522a(b) of the Privacy Act of 1974, as amended. Pursuant to 5 U.S.C. 522a(b)(3), records may be disclosed as a routine use to Federal, State
and local health departments for compliance with public health communicable disease reporting laws in accordance with 42 U.S.C. 264. A complete list of routine uses may be found in the applicable System of Records Notice,
United States Military Entrance Processing Command (USMEPCOM) Integrated Resource System (USMIRS), A0601-270 at: https://www.federalregister.gov/documents/2021/04/21/2021-08286/privacy-act-of-1974system-of-records.
DISCLOSURE: Voluntary; however, failure to provide the requested information may result in an inability to process your application for enlistment or appointment in the Armed Forces. For current Armed Forces members,
failure to provide the requested information may result in being placed in non-deployable status.
Additional system of records notices:
Physical/Medical Evaluation Records
Army: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/569965/a0040-3b-dasg/
Navy: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570339/nm01850-2/
Air Force: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/569861/

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.

2.a SOCIAL SECURITY NO. b. DoD ID NO. (If applicable) 3. TODAY'S DATE
(YYYYMMDD)

1. LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX)

4.a. HOME ADDRESS (Stress, Apartment No., City, State, and ZIP Code) 5. EXAMINING LOCATION AND ADDRESS (Include Zip Code)

b. HOME TELEPHONE (Include Area Code)

c. EMAIL ADDRESS

X ALL APPLICABLE BOXES:
6.a. SERVICE
Army
Navy
Marine Corps
Air Force

Coast Guard
USPHS
Space Force
NOAA

DRAFT

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

b. COMPONENT
Regular
Reserve
National Guard

c. PURPOSE OF EXAMINATION
Retention
Other (Specify)
Separation
Medical Board
Retirement

8. CURRENT MEDICATIONS (Prescription and Over-the-Counter)

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

10.a. Tuberculosis

YES NO

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

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, pollens,
etc.
e. Shortness of breath

h. Swollen or painful joint(s)

f. Bronchitis

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

g. Wheezing or problems with wheezing

l. Bone, joint, or other deformity

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
j. Sinusitis

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 to any bone or joint
k. Any need to use corrective devices such as prosthetic devices, knee brace(s), back

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

11.a. Severe tooth or gum trouble

d. Jaundice or hepatitis (liver disease)

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 or 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

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

l. Sexually transmitted disease (syphilis, gonorrhea, chlamydia, genital 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

d. Tumor, growth, cyst, or cancer

DD FORM 2807-1, OCT 2018
PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

Controlled by: OUSD(P&R)
Page 1 of
CUI Category: PRVCY, HLTH
LDC: FEDCON
POC: [email protected]

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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

YES NO
19. Have you been refused employment, or been unable to hold a job or stay
in school because of:
a. Sensitivity to chemicals, dust, sunlight, etc.

15.a. Dizziness or fainting spells
b. Frequent or severe headache
c. A head injury, memory loss or amnesia
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

20. Have you ever been treated in an Emergency Room? (If yes, for what?)

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

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.)

e. Heart trouble or murmur
f. High or low blood pressure
17.a. Nervous trouble of any sort (anxiety or panic attacks)

23. Have you ever had any illness or injury other than those already noted?
(If yes, specify when, where, and give details.)

b. Habitual stammering or stuttering
c. Loss of memory or amnesia, or neurological symptoms
d. Frequent trouble sleeping
e. Received counseling of any type
f. Depression or excessive worry

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

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
c. Any abnormal PAP smears
d. First day of last menstrual period (YYYYMMDD)

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.)
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.)

DRAFT

28. Have you ever been denied life insurance?

e. Date of last PAP smear (YYYYMMDD)

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, OCT 2018
PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

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CUI (when filled in)
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

DRAFT

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

DD FORM 2807-1, OCT 2018
PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

d. DATE SIGNED
(YYYYMMDD)
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