Dd form 28071, mar 2015 dod exception to sf 93 approved by icmr, august 3, 2000. Complete, sign and submit dd form 28071, report of medical history. Additional questions have been added to improve its usefulness to the accessions medical prescreening process. Dd form 28071, oct 2003 page 2 of 3 pages last name, first name, middle name suffix social security number b. Tricare online patient portal service separationretirement. This form is to be completed by each individual who requires medical processing in accordance with army regulation 40501. A copy of this form will be released to the department of veterans affairs. Please access your health record information to help complete your report of medical. History form dd 28071 prior to your dod shpe or va appointment. Its used by meps during the meps medical examination. I understand that the falsification or other nondisclosure of material medical information may result in the immediate close out of my application or my separation from active duty without benefits at any time during my career. General instructions for completing medical examination forms. Nervous trouble of any sort anxiety or panic attacks e. Va separation health assessment veterans benefits administration.
A dd form 28071 is a department of defense form is used for gathering medical information for applicants to military service. Loss of memory or amnesia, or neurological symptoms 17. Dd form 28071 oct 2018 page 2 of 3 pages last name, first name, middle name suffix social security number b. Sexually transmitted disease syphilis, gonorrhea, chlamydia, genital. Dd form 28071, jul 2001 dod exception to sf 93 approved by icmr, august 3, 2000. This information is for official and medically confidential use only and will not be released to unauthorized persons. Adverse reaction to serum, food, insect stings or medicine l. To be used by the medical services to provide a comprehensive medical assessment for active and reserve component service members separating or retiring from active duty. Please return this instruction sheet with your dd form 28071, report of medical history, to. Dd form 28072 medical prescreening of medical history report. Dod exception to sf 93 approved by icmr, august 3, 2000. Dd form 28071 download fillable pdf or fill online report of. Military physicians determine if an applicant can be accepted or should be disqualified on medical grounds with the help of it.
Current dd 28071 report of medical history no older than one year will be required for assimilation, permanent promotion, and long term training. Dd form 28071 report of medical history legal forms. Fill out the report of medical history online and print it out for free. Replaces the existing medical prescreen form dd form 28072, aug 2011.
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