DD Form 2807-2 Accessions Medical History Report

CUI (when filled in)
OMB No. 0704-0413
OMB Approval Expires:
20241031

ACCESSIONS MEDICAL HISTORY REPORT

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 this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, 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 ADDRESS.

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.
PURPOSE: To obtain medical data for determination of medical fitness for enlistment, induction, appointment, and retention for applicants and members of the Armed Forces. 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-1974-system-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/

SECTION I – APPLICANT INFORMATION
1. LAST NAME – FIRST NAME – MIDDLE INITIAL (Suffix)

5. (X each item)

2. AGE

3. DATE OF BIRTH
(YYYYMMDD)

4.a. SOCIAL SECURITY NUMBER 4.b. DoD ID NUMBER
(If applicable)

6.a. SERVICE PROCESSING FOR (X as applicable)
b. GENDER

Army

Space Force

Navy

Marine Corps

Male

Male

Air Force

Coast Guard

USPHS

Space Force

Female

Female

NOAA

Other:

a. SEX (at birth)

U.S. Service Academy

Commission

ROTC Scholarship

Reserve
National Guard

8. POSITION (If current Federal Employee) (Job Title, Grade, Component)

7. PURPOSE OF EXAMINATION (X as applicable)
Enlistment

6.b. COMPONENT
(X as applicable)
Regular

Other:

DRAFT

SECTION II - APPLICANT (OR PARENT/GUARDIAN) AUTHORIZATION STATEMENT

• I Have read and understand the warning and penalties that are associated with providing a false statement.
• I Agree that all protected health information and personally identifiable information (PHI/PII) or data disclosed by myself or others on my behalf with my consent during the
accession process is no longer protected by federal Health Insurance Portability and Accountability Act (HIPAA) Privacy Rules and may be further disseminated as needed.
• I Authorize release of medical records and information relating to grades, performance, individual education plans, and disciplinary proceedings. Under the Family
Educational Rights and Privacy Act (FERPA), United States Military Entrance Processing Command (USMEPCOM)/Department of Defense Medical Examination Review
Board (DoDMERB) is authorized to receive all of my
education/disciplinary records for evaluation of my suitability for Military Service.
• I Understand that a medical examination is part of the accession evaluation, may require several visits to the Military Entrance Processing Station (MEPS), or DoDMERB
contracted medical center. I may have blood work and/or other medical tests, procedures such as cerumen removal, and/or specialty consultations performed as part of my
processing.
• I Understand that the results of the examination, tests, and consults are not performed as part of an individual healthcare treatment plan, but will be reviewed and
considered as part of my accession application file.
• I Understand that the MEPS/DoDMERB medical staff are not my healthcare providers. If I do not receive notice of an abnormal result of a test or a consultation, I am not to
assume that the result is normal. Furthermore, if any test or consultation results are abnormal, then I am responsible for obtaining those results from the MEPS/DoDMERB
contracted medical center. I am also responsible for any necessary follow-up evaluations and/or treatment. If I am notified to return to the MEPS/DoDMERB contracted
medical center to discuss medical results, it is my responsibility to take quick action to return to the MEPS/DoDMERB contracted medical center.
• I Understand that neither USMEPCOM nor DoDMERB are financially responsible for costs associated with any necessary follow-up evaluations and/or treatment based on
my screening evaluation.
• I Understand that any concerns that I have about my health and healthcare are my responsibility to address with my personal healthcare provider(s).
• I Understand that I must provide required documentation regarding my health history which, upon my accession, will become part of my Service member lifecycle medical
treatment record.
• I Authorize a MEPS/DODMERB contracted medical center to perform my accession medical evaluation.
• I Understand that I have the right to refuse to sign this authorization, however I also understand that failure to do so will prevent my further processing.
• I Understand that this authorization will expire four years from the date of the signature below, or sooner if written request is received by the USMEPCOM/DoDMERB
Privacy Office. I have the right to revoke this authorization in writing, except to the extent that the DoD has acted in reliance on this information.
1. APPLICANT AUTHORIZATION AND CERTIFICATION
I Certify that the information on this form is true and complete to the best of my knowledge and belief, and no person has advised me to conceal or falsify any information about my
medical and mental/behavioral health history.
a. SIGNATURE

b. DATE SIGNED
(YYYYMMDD)

2. PARENT OR GUARDIAN AUTHORIZATION (Signature is mandatory if applicant is a minor)
a. NAME (Last, First, Middle Initial)

b. SIGNATURE

c. DATE SIGNED
(YYYYMMDD)

3. RECRUITING REPRESENTATIVE CERTIFICATION: (If applicable) I certify that all applicant information above is complete and true to the best of my knowledge.
a. NAME (Last, First, Middle Initial)

DD FORM 2807-2, DEC 2021
PREVIOUS EDITION IS OBSOLETE.

b. RECRUITER IDENTIFICATION NUMBER

c. SIGNATURE

CUI (when filled in)

d. DATE SIGNED
(YYYYMMDD)
Controlled by: OUSD(P&R)
CUI Category: HLTH, PRVCY
LDC: FEDCON
POC: 703-695-5527

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CUI (when filled in)
LAST NAME – FIRST NAME – MIDDLE INITIAL (Suffix)

SOCIAL SECURITY NUMBER

DoD ID NUMBER (If applicable)

SECTION III - MEDICAL HISTORY
1. Medications: any prescription or over the counter medication(s) taken regularly or as
needed (list each and explain in SECTION IV)

2. Allergies: reaction to food(s), insect bites/stings, medication(s) or other substances (list
each and explain in SECTION IV)

Read each of the following questions and answer by checking “YES” or “NO”. Every question must be answered. Every “YES” answer must be explained in SECTION IV. Explain each
item to the best of your ability. Your medical records may be requested to clarify your medical history.
HAVE YOU EVER HAD OR DO YOU NOW HAVE:

YES

NO

HAVE YOU EVER HAD OR DO YOU NOW HAVE:

EYES/VISION:

UPPER EXTREMITIES: (Continued)

3. Double vision

60. Dislocated shoulder, elbow, or wrist

4. Detached retina or surgery to repair a detached retina

LOWER EXTREMITIES:

5. Keratoconus, glaucoma, cataracts or surgery for cataracts

62. Knee injury resulting in ligament/cartilage tear, instability, or locking

7. Night blindness

63. Any pain, swelling, weakness, numbness, or stiffness of the hip, knee, ankle, foot, or toes

8. Any other eye condition, injury, or surgery/procedure

64. Dislocated hip, knee, ankle, or foot

EARS/HEARING:

MISCELLANEOUS CONDITIONS OF THE EXTREMITIES:

9. Cholesteatoma

65. Bone, muscle, or joint deformity, injury, or persistent pain/swelling

10. Ear drum perforation or tubes inserted into the ear drum(s) in the past 12 months

66. Impaired use of arms, hands, fingers, legs, feet, or toes (any reason)

11. Any other ear surgery or procedure including mastoidectomy

67. Joint swelling/inflammation such as arthritis, gout, or bursitis

12. Loss of balance or vertigo

68. Compartment syndrome, shin splints, or stress reaction/fracture
69. Any surgery of the bone or joint such as placing a screw, plate, rod, pin, prosthetic/graft or
arthroscopy
70. Any use of prescribed corrective/prosthetic devices such as a brace, back support, heel lift, or
orthotic inserts

13. Hearing loss or use of hearing aid(s)

NOSE, SINUSES, MOUTH, AND LARYNX:
14. Ear, nose, or throat conditions such as vocal cord dysfunction
15. Recurrent nose bleeds, chronic sinus infections, or sinus surgery

VASCULAR:

16. Absence of, or disturbance of sense of smell

71. Abnormal (high or low) blood pressure

17. Any surgery of the face, throat, or jaw

DENTAL: (If you wear braces/aligners, then you must submit a letter from your orthodontist stating that

72. Pale, blue, or numb fingers or toes with exposure to cold such as Raynaud’s phenomenon/
disease

active orthodontic treatment will be completed before beginning active duty)

73. Kawasaki disease

18. Braces or aligners

SKIN:

19. Any tooth or gum problems

74. Acne that required prescription medication(s)

LUNGS, CHEST WALL, PLEURA, AND MEDIASTINUM:
20. Asthma, asthmatic bronchitis, wheezing, shortness of breath, or other breathing problems
worsened by exercise, weather, pollens, etc.
21. Prescription for an inhaler, steroids, or any other medication for breathing problem
23. Chronic cough or frequent coughing at night
24. Collapsed lung or other lung condition(s)
25. History of chest, chest wall, or breast surgery

HEART:
26. Heart murmur or valve problem(s)
27. Palpitations, skipped/abnormal heartbeats, or pounding heart
28. Chest pain/pressure or an abnormal electrocardiogram (EKG)
29. Heart surgery

NO

61. Foot conditions such as plantar fasciitis, heel spur, or painful bunions

6. Vision correction procedure such as Lasik, PRK, or lens implant

22. Pneumonia

YES

75. Skin rash such as atopic dermatitis, eczema, or psoriasis
76. Any other skin condition such as recurrent hives, abscesses (hidradenitis), pilonidal cyst, or
cancer (melanoma)

DRAFT

30. Any other heart condition

BLOOD AND BLOOD FORMING SYSTEM:
77. Anemia such as iron deficiency, sickle cell, or thalassemia
78. Blood clot(s), a clotting disorder, or history of taking a blood thinner
79. Absence or removal of the spleen

80. Prolonged bleeding such as after an injury or dental procedure
81. Any other blood or circulation condition

SYSTEMIC:

82. Severe allergic reaction to any substance requiring emergency care
83. Tested positive for tuberculosis (skin or blood test), or lived with someone who had it
84. Immune system condition such as rheumatoid arthritis, lupus, multiple sclerosis, or AIDS
85. Sexually transmitted disease such as herpes, syphilis, gonorrhea, chlamydia, or HIV

ABDOMEN AND GASTROINTESTINAL SYSTEM:

86. Rhabdomyolysis

31. Problems of the stomach, esophagus, or intestine such as ulcer(s)

ENDOCRINE AND METABOLIC:

32. Frequent indigestion/heartburn, difficulty swallowing, or eosinophilic esophagitis
33. Gallbladder disease or gallstones
34. Hepatitis or jaundice (except neonatal jaundice)
35. Hernia
36. Any abdominal surgery/endoscopy such as appendectomy, bowel resection, hernia repair, or
colonoscopy
37. Weight loss surgery such as gastric bypass or lap banding
38. Chronic or recurrent intestinal disease such as irritable bowel syndrome, inflammatory bowel
disease, or celiac disease
39. Anorectal disease, blood from the rectum, or hemorrhoids

FEMALES ONLY:

87. Thyroid conditions such as goiter or hypo/hyperthyroidism
88. Diabetes or hypoglycemia (low blood sugar)
89. Any other endocrine (hormone) condition such as growth hormone deficiency, adrenal
insufficiency, or hypo/hyperparathyroidism

NEUROLOGIC:
90. Stroke, aneurysm, or bleeding in or around the brain
91. Frequent or severe headaches such as migraines, cluster, or tension
92. A head injury, concussion, or skull fracture
93. Infection of the brain or spinal cord such as abscess, meningitis, or encephalitis
94. Seizures, epilepsy, or convulsions
95. Syncope or fainting spells

40. First day of the last menstrual period (YYYYMMDD)
41. A change in menstrual pattern (other than pregnancy)
42. Pregnancy
43. Any abnormal PAP test
44. Endometriosis, uterine fibroid, or ovarian cyst
45. Any other gynecological disorder that required evaluation, treatment, or surgery

96. Any other neurologic condition such as paralysis, myasthenia gravis, Tourette’s, or memory loss

SLEEP:
97. Sleep apnea
98. Sleepwalking, narcolepsy, or difficulty with sleep such as falling/staying asleep

LEARNING, PSYCHIATRIC, AND BEHAVIORAL:

URINARY SYSTEM:

99. Attention Deficit or Hyperactivity disorder (ADD/ADHD), dyslexia, autism spectrum, or other
learning disorder
100. A behavioral/mental health condition such as anxiety/panic attacks, depression, adjustment
disorder, PTSD, personality disorder, addiction, or drug/substance abuse including alcohol
101. Evaluation or treatment either with medication or counseling for any behavioral/mental health
condition
102. Eating disorder such as anorexia or bulimia

49. Absence of, or a congenital abnormality of a kidney such as horseshoe kidney

103. Self-inflicted injury such as cutting or burning

50. Blood or protein in urine

104. Suicidal thoughts, gesture, or attempt

51. Painful or difficult urination

105. Admission to a hospital for any behavioral/mental health condition

52. Kidney stone

TUMORS AND MALIGNANCIES:

MALES ONLY:
46. Undescended/absent testicle(s), or testicular implant
47. Any scrotal mass, swelling, or pain
48. Prostate problems

53. Kidney or urinary tract disease, surgery, or infection
54. Bedwetting or treatment for bedwetting in the past 12 months

SPINE AND SACROILIAC JOINTS:
55. Back or neck pain, or herniated disc
56. Abnormal curvature of any part of the spine
57. Vertebral fracture or stress injury of the spine such as spondylolysis
58. Back or neck surgery

UPPER EXTREMITIES:
59. Any pain, swelling, weakness, numbness, or stiffness of the shoulder, elbow, wrist, hand, or
fingers

DD FORM 2807-2, DEC 2021
PREVIOUS EDITION IS OBSOLETE.

106. Any cancer, malignancy, tumor, or cyst

MISCELLANEOUS:
107. Cold/heat intolerance or injury such as frostbite or heatstroke

SUPPLEMENTAL QUESTIONS:
108. Prosthetic body part or joint
109. Any medical treatment/surgery from a Hospital, Emergency Room, Surgical Center or Urgent
Care
110. Previous medical disqualification for Military Service
111. Discharge from Military Service for any reason (provide reason, date, and type of discharge)
112. Disability award or compensation for an injury or other medical condition

CUI (when filled in)

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CUI (when filled in)
LAST NAME – FIRST NAME – MIDDLE INITIAL (Suffix)

SOCIAL SECURITY NUMBER

DoD ID NUMBER (If applicable)

SECTION IV – APPLICANT COMMENTS
Explain all "YES" answers to questions above. Write the item number and provide details to include the following: description of the problem/condition, date of
onset of the problem/condition, date of treatment, name of health care provider, clinic, center, hospital along with City and State. Comment on the current status
of the problem/condition. Attach additional sheet(s) if necessary, and sign and date each additional sheet. Attach copies of all applicable medical records.

DRAFT

DD FORM 2807-2, DEC 2021
PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

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CUI (when filled in)
LAST NAME – FIRST NAME – MIDDLE INITIAL (Suffix)

SOCIAL SECURITY NUMBER

DoD ID NUMBER (If applicable)

SECTION V – MEDICAL PROVIDER SUMMARY
The medical provider will review all applicant comments on "YES" answers, and all submitted supporting medical documentation. The provider will comment
below on each "YES" answer. Attach additional sheets if necessary.

DRAFT

DD FORM 2807-2, DEC 2021
PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

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CUI (when filled in)
LAST NAME – FIRST NAME – MIDDLE INITIAL (Suffix)

SOCIAL SECURITY NUMBER

DoD ID NUMBER (If applicable)

SECTION VI - PRESCREEN PROCESSING DETERMINATION
1.a. MEDICAL PROCESSING STATUS
1.b. REVIEWER INITIALS
PA

PH

RJ

METR

1.c. DATE (YYYYMMDD)

KEY: PA = Processing Authorized; PH = Processing Hold; RJ = Return Justified; METR = Medical Evaluation and/or Treatment Records
2. AUTHORIZING MEDICAL PROVIDER
a. NAME (Last, First, Middle Initial)

b. SIGNATURE

c. DATE SIGNED (YYYYMMDD) d. NUMBER OF ADDITIONAL
SHEETS ATTACHED

SECTION VII – INTERVIEWING MEDICAL PROVIDER COMMENTS

DRAFT

3. INTERVIEWING MEDICAL PROVIDER
a. NAME (Last, First, Middle Initial)

DD FORM 2807-2, DEC 2021
PREVIOUS EDITION IS OBSOLETE.

b. SIGNATURE

CUI (when filled in)

c. DATE SIGNED
(YYYYMMDD)

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