MEET THE STAFF

Transcript MEET THE STAFF

Madigan Army Medical Center

Welcome to Medical Evaluation Boards (MEBs)

Please Silence ALL Phones, PDA’s, and Pagers.

DA 5893 Counseling Checklist

Checklist # 1 3

BLUE PACKET CONTENTS

Left Pocket Right Pocket MAMC Briefing Slides MEDCOM Briefing Slides APDES Handbook FACT Sheet (TAMP) Personnel Data letter TSGLI ACAP Transition Svc Legal Svc Information My MEB (AKO) Checklist # 5 4

GOALS for Today’s Briefing

1. Introduce you to Medical Evaluation Board (MEB) Process 2. Introduce you to Physical Evaluation Board (PEB) Process 3. Answer common MEB/PEB questions 5

A Few ACRONYMS

MEB = Medical Evaluation Board PEB = Physical Evaluation Board PEBLO = PEB Liaison Officer MEBT = Medical Evaluation Board Technicians NARSUM = Narrative Summary (or dictation) WTB/WTU = Warrior Transition Battalion (Unit) 6

The MAMC MEB Staff

Medical Board Technicians & Clerks: Make your appointments, track board through the process.

Ms. Paige Ms. Coleman Ms. Edwards Mr. Der Mr. Espinoza Ms. English A-C D-G, POM, CBWTU H-L M-R S-Z TDRL 968-1638 968-5057 968-5058 968-3438 968-3744 968-1855 7

The MAMC MEB Staff (cont’d.) PEBLOs

Physical Evaluation Board Liaison Officers (PEBLOs): Review board packet, counsel soldiers on benefits and appeals.

Ms. Burnham Ms. High Ms. Johnson Ms. Levene Ms. Miracle Ms. Robinson Ms. Gorden A-B, POM C-F G H I-L, CBWTUC M-R S-Z 968-2026 968-6019 968-3437 968-2564 968-1679 968-3649 968-3686

Office Hours Walk- In Hours 1000 - 1600 HRS

Monday - Wednesday & Friday

CLOSED EVERY THURSDAY

CLOSED on Federal Holidays ** Inclement Weather**

WHAT IS PDES?

 The entire Physical Disability Evaluation System  2 Parts MEB and PEB 

MEB

- Medical evaluation Board  -

Gathers

together the medical information 

PEB

- Physical Evaluation Board  -

Determines disability percentage

medical information based on 10

MEB / PEB: “6 Letters, 6 Steps”

1. PHYSICAL EXAM 2. CONSULTS 3. NARRATIVE SUMMARY (NARSUM) 4. MEB REVIEW 5. PEB 6. PDA

DA Physical Disability Process

Physician MMRB FFD MEB Initiated

MAMC Responsibility:

•

Washington, Idaho, California (incl. CBWTUC), Oregon, & Nevada

•

AC, RC, & TDRL MEB MAMC Responsibility Standard = 90 workable days Madigan Average = 92 workable days

PEB at Ft. Lewis PEBLO Counsels Soldier & Assists VA Transition PDA in D.C.

Orders 12

How long does it take to complete a Medical Board?

From the time you are notified, by the MAMC MEB staff that you will undergo a Medical Board, our goal is to send the case to the PEB within 90 workable days.

THIS IS ONLY AN ESTIMATE

What is a Medical Board?

It is a “word picture” of your medical condition, military history and lifestyle.

How did I become a Medical Board?

**3 Ways to become an MEB: 1. Referred by a Fitness For Duty Evaluation (Commander) 2. Referred by MMRB (Medical MOS Reclassification Board) 3. Referred by Doctor* (most common)**

A Medical Board is

NOT

...

 An MOS reclassification Board (MMRB) any MOS reclassification would have occurred at the MMRB.

 You WILL NOT sit in front of a panel of board members. The MEB is simply a physician’s evaluation and recommendation.

History & Physical Examination (DD 2807 & DD 2808)

When you complete your forms (DD 2807 & DD 2808), address ANY and ALL medical conditions which you have.

Consults

If your MEB Provider wants you to be evaluated by another specialty clinic, they will request a consult with that clinic. Please notify your MEBT ASAP when this happens.

DO NOT CALL TRICARE FOR AN APPOINTMENT – SEE YOUR MEBT!

Narrative Summary (NARSUM)

It is in your best interest, to tell your MEB Provider about any & all medical problems you have. If necessary, they will be reviewed and addressed in your board.

Your MEB Provider CANNOT read your mind. If you do not tell them all your problems, they cannot help you.

What are the possible MEB recommendations?

The MEB Provider can recommend: Return to Unit without limitations Return to Unit with limitations Refer to Physical Evaluation Board (PEB) Other 20

MEB Review: Who reviews my MEB?

1 st : Two Doctors, your board doctor and one other doctor 2 nd

: YOUR PEBLO

3 rd : The Madigan Deputy Commander for Clinical Services (or his representative) 4 th :

YOUR PEBLO

Independent Review (IR)



An independent review is an opportunity for an independent medical provider to review your COMPLETED medical board .



They will determine if the board has been adequately completed and will provide you written documentation to support any missing diagnosis .



The information they provide you can assist you with your appeal .



All information pertaining to your IR will be forwarded to the PEB with your case .

22 Checklist # 16 &19

APPEAL VS STATEMENT



SHOULD I APPEAL??



SHOULD I MAKE A STATEMENT??

S H O U L D I D O B O T H

Can I write on my behalf?

If you feel you have information which would help the MEB/PEB, you can write a statement on your own behalf, which will be included in your PEB packet.

Can I appeal the MEB?



Yes.

 You have

7 calendar days

to review board. Decision for IR will be decided during this time. The PEBLO will attempt to schedule your appointment within 5 days. You will have 7 calendar days (from the date of your appointment) to make your election of concur/nonconcur (appeal).

MEB Packet

è è Coversheet (DA 3947) Narrative Summary ( NARSUM/dictation ): written by your doctor. Provides a “word picture” of your condition, history and status. Provides a recommendation. è è Consults from clinics you visited.

Current History & Physical 2808).

(DD 2807 & è Copy of your profile.

Personnel Data**

è è è è ERB/ORB/PQR Commander’s Performance Statement NCOERs/OERs ( E-5 And above ) ( Last 3 ) DA 4187 ( Name changes, loss of rank, promotions, etc ) è è DA 2648 ( COMPLETED ACAP Checklist) LES ( Current End of Month ) **RC soldiers may have additional requirements. 27

Completed PEB Packet



MEB PACKET



PERSONNEL DATA



HEALTH RECORD

Line of Duty (LOD)

A LOD is

may be required

for any condition that is the direct result of an accident or injury which occurred while entitled to Active Duty Pay. Examples:

Motor Vehicle Accident, Misconduct, Drugs, Alcohol, TPU/M-Day soldiers

What about flags or UCMJ?

Court martial procedures will stop your medical board.

Chapter 14 is done in conjunction with the medical board. Which action has precedence will be determined once the MEB is completed. All other Chapters are put on hold until the Medical Board is completed.

Immediately report any flags or adverse actions to your PEBLO 31

What if I am about to ETS?

Soldiers can be retained medically for the purpose of completing the medical evaluation board.

NOTIFY YOUR PEBLO 30 Days PRIOR!

ENLISTED - 6 month Interval OFFICER - 3 month Interval Checklist # 23 32

What if I am about to PCS?

Soldiers who come down on PCS orders or are currently on orders cannot PCS until the Medical Board is complete.

NOTIFY YOUR MEBT IMMEDIATELY

Your MEBT will obtain the paperwork necessary to delete or defer your PCS orders until the board is complete 33

What if I put in for retirement?

DON’T

Soldiers who have submitted for retirement and have received orders will have their orders revoked until completion of the Medical Board.

**NOTIFY YOUR PEBLO IMMEDIATELY**

Is there any way I can stay in?

YES,

you can request Continuation on Active Duty/Active Reserve Component (COAD/COAR).

CRITERIA FOR CONSIDERATION:

15 YEARS BUT LESS THAN 20 SHORTAGE MOS INJURY COMBAT RELATED

HRC MAKES THE DECISION

NOT THE PEB

Checklist # 17 35

PEB: What does the Physical Evaluation Board Do?

The PEB reads all documentation and determines your fitness status:

“FIT FOR DUTY” or “UNFIT FOR DUTY”

There are 2 types of Fit For Duty

NORMAL FIT FOR DUTY

You are found fit because you can do the majority of your duties in your current MOS.

PRESUMPTIVE FIT FOR DUTY

You have submitted for retirement or are at your Retention Control Point (RCP).

Can I appeal a FIT for DUTY?

YES

The PEB President will decide if you will appear in front of a formal board.

“FIT for DUTY”

Once you have been found FIT for DUTY, you will receive a FIT letter from the Physical Disability Agency, you will be released from all restrictions imposed during the medical board process (i.e. You are now deployable ).

YOUR MEB PERMANANT PROFILE WILL BECOME A PART OF YOUR MEDICAL RECORDS.

“UNFIT for DUTY”

When the PEB determines UNFIT for DUTY, they also determine the % of unfitness. ----% Existed Prior to Service (EPTS) 0% - 20% Severance Pay Calculation 30% or Medical Retirement

Existed Prior to Service (EPTS)

Separation is given without Disability Benefits (monetary or medical) [Exception “8 Year Rule”]

***LIMITED BENEFITS ARE GIVEN THROUGH INVOLUNTARY SEPARATION ***SEE TRANSITION POINT WALLER HALL

Checklist # 40

0 - 20 % - Severance Pay

2 MONTHS BASE PAY FOR EACH YEAR OF ACTIVE SERVICE (

UP TO 19 YRS

) 2 X Month Base Pay X #YRS

EXAMPLE: 6 YEARS 10 MONTHS ACTIVE SERVICE WOULD BE 2 X MONTH BASE PAY X 7 = $$$ NEW!! NEW!! NEW!! Non-Combat - Minimum 3 years In Combat Zone – Minimum 6 years

Combat Zone Vs Combat Related

 Combat Zone  Any injury or illness that occurs in a combat Zone.

 (example: Tripped and fell walking to the mess hall, while deployed in Iraq)  Combat Related  Any injury or illness that occurs while engaged in a combat mission.

 (example: IED blast while on patrol) 43

0 - 20% - Severance Benefits

In addition to Severance Pay, you and your family are entitled to the following:

Medical Care 180 days

Medical Retirement - 2 types

Temporary Disability Retirement List (TDRL) - Re-evaluated every 18 months - Can be retained a maximum of 5 years Permanent Disability Retirement List (PDRL) - Permanent Retirement

Retirement Benefits

Eligible for all benefits awarded to 20 year length of service retirees:

MEDICAL THROUGH TRICARE DENTAL THROUGH TRICARE COMMISSARY AND PX

Can I appeal this recommendation?

If you disagree with an “UNFIT for DUTY” determination, you can appeal in two ways: 1. IN WRITING 2. REQUEST A FORMAL BOARD with LEGAL REPRESENTATION

YOU HAVE 10 CALENDAR DAYS TO MAKE YOUR DECISION

NOTE

: If you choose to appeal in writing, and the appeal is rejected, you may lose your right to request a formal board.

PDA – Physical Disability Agency

 Once your case has been completed by the PEB, it is forwarded to the Physical Disability Agency for final review.  After PDA processing, you will be placed on TRANSPROC for orders.

 Once you are on TRANSPROC, your PEBLO will contact you so you can go to Waller Hall (transition) to pick up your packet. Your command will need to sign a 4187 so you can go back to transition and get your final orders.

Please give a copy to your PEBLO as soon as you receive your final orders so your case can be closed.

LEAVE/PERMISSIVE TDY

Your Command will determine what leave and/or Permissive TDY will be granted.

What about Additional Benefits?

If you are separated or medically retired, Your PEBLO will:

  

Refer you to the VA to start your claim Refer you to the TRICARE Service Center Discuss other services available on an individual basis

What about confidentiality?

(HIPPA)

  Your medical board is personal and private.

Limited information can be provided to your unit:  IF YOU ARE A MEDICAL BOARD  WHAT IS THE BOARD’S CURRENT STATUS  IF YOU WERE FOUND FIT OR UNFIT

Family members do not have automatic access to your medical records/board status.

KEEP EVERYONE CONCERNED INFORMED

PTSD (Post Traumatic Stress Disorder)

 The Diagnosis of PTSD may be given when a traumatic event (stressor) has occurred, in which the soldier experienced, witnessed or was confronted with actual or threatened death or serious injury or threatens the physical integrity of the Soldier or of others.” 

NOTE: Combat does not automatically justify a diagnosis of PTSD

PTSD (Post Traumatic Stress Disorder)

 Any additional information can help the PEB make their final determination.

Types of information could be: 

Statement from your in-theater commander



Statements from fellow Soldiers who witnessed the same events with you.

Resources

 There are additional resources available to you throughout this process.

 WTB Contact Rep  Case Manager  Legal Counsel  Ombudsman Checklist # 7 54

WTB Contact Representatives

Assist with Personnel Data for WTB Soldiers.

 A CO  B CO  C CO Wilma Agular Floretta Stevens Monique Baker 966-2567 966-2715 966-2958 55

Case Manager



Continues coordinating all your medical (non-MEB) appoints.



Continue working with your case manager if you have questions.

Legal Counsel (FLOSC)

 Ft Lewis Office of Soldier’s Counsel (FLOSC) is available to help soldiers throughout the different stages of the MEB and PEB.

 Advise and represent you, not commanders or members of the MEB/PEB, about your legal rights as you work through your medical board.

 Give a general overview briefing daily or you can meet individually with an attorney. 57 Checklist # 10

Ombudsman

 The Ombudsman team provides a neutral and informal process to assist Warriors in Transition and their Family Members. Emphasis includes:  Health care issues, Physical disability processing, Medical retention, Finance, Legal, Transition benefits, VA, TSGLI  Assist with writing appeals (at any stage of the board)  Ombudsman  Ador Yabut 253-320-9725 58 Checklist # 30

Every SOLDIER will be able to track the progress of their MEB/PEB via the My MEB Portal on AKO.

There are two ways to access you’re my MEB:

Type the following address into your Internet Browser

https://www.us.army.mil/suite/page/417118

Or From your AKO homepage click on

Self Service / My Medical / My MEB

59 Checklist # 3

How can I make this as painless as possible?

IGNORE RUMORS

All cases are unique. Until the PEB makes a determination, NO ONE KNOWS WHAT THE OUTCOME WILL BE .

BE AVAILABLE

Always provide accurate phone numbers.

If you change units or assignments, let your PEBLO know.

Never leave town without telling your PEBLO.

BE AT YOUR APPOINTMENTS

Don’t miss any of your appointments Be on time with your ID card

Be in the appropriate Uniform Be prepared to wait

What happens if you miss a MEB Appointment?



You will be escorted to EVERY MEB appointment if you are late or do not show up.

 It is YOUR responsibility to show up to your appointments at least 15 minutes early.

 Your unit will be required to provide the escort.

BE INFORMED

Ask questions. Ask how long each step should take and follow-up. This is

YOUR

career and

YOUR

board. Take the time to review all documents for accuracy. Provide accurate and timely information.

YOU ARE THE KEY TO YOUR BOARD.

Our Address & Phone Number

MADIGAN ARMY MEDICAL CENTER ATTN: MCHJ-PDP (PEBLO) 9040 REID STREET TACOMA, WA 98431 FAX: (253) 968-1678 DSN 782-1678

QUESTIONS?

MEB INTAKE FORMS

 Initiate Board paperwork      Soldier Data Sheet DD Form 2807-1(Medical History) DD Form 2808 (Physical Exam) DD Form 2870 (Privacy Statement) MEDCOM Form 756-r (E-mail authorization) 68

Soldier Data Sheet

Please Write Legibly Medical Evaluation Board Soldier Data Sheet

Tech LAST name: ADMIN ONLY PEBLO FIRST name: MI: SSN: GENDER (circle one) Male Female BIRTH DAY: MMDDYYYY AGE:

LOCAL

CITY: Mailing Address: STATE: ZIP CODE

Were you deployed to:

Nobel Eagle

(circle all that apply)

Operation Iraq Freedom None Operation Enduring Freedom Operation Joint Guardian CIRCLE ONE I AM LEFT HANDED I AM RIGHT HANDED Have you applied for Retirement or Early Release? YES NO LOCAL Phone: ( ) Home Phone: ( ) Cell Phone: ( ) Unit Phone: ( ) Duty Phone: ( ) Please only circle ONE Active Component USAR-AGR USAR-weekend USAR-Mobilized NG-AGR NG-Mobilized NG-M-day If you are in the USAR, what RSC? ____________________ RANK: PAY GRADE: PMOS/AOC: If you are in the NG, what state? ________________ PEBD: MMDDYYYY Basic Active Service Date: MMDDYYYY: Current Tour of Duty: MMDDYYYY: Description: TOTAL Active Duty Time: Years: ETS Date MMDDYYYY: Months:

(USAR/NG ONLY)

Good Years:

(USAR/NG ONLY)

End MOB Date MMDDYY: Unit Name: Company: Brigade: UIC: Duty Station: FULL UNIT Mailing Address: ________________________________________________ Street Address _______________ City _______ State Why are you being Boarded? (List ONE condition ONLY, all other medical problems list on back) ____________ Zip If you are found UNFIT, do you want a waiver to remain on Active Duty or in the Reserves?

YES NO ADMIN ONLY if Refered by MMRB, date the board convened: If Doctor Refferred, List

DOCTOR

CLINIC

, and

DATE

on pink slip

DOCTOR CLINIC

Briefing Date PEBLO interviewed

DOCTOR

Date Interviewed

CLINIC

PEBLO interviewd

DATE

Tech Interviewed

DATE

Tech Interviewed 69

DD form 2808 Page 1

2 . SOCIAL SECURITY NUMBER REPORT OF M EDICAL EX AM INATION 1 . DATE OF EX AMINATION

(YY YYMMDD)

555-55-5555 PRIVACY ACT STATEM ENT AUTHORITY:

1 0 USC 50 4 , 5 05 , 5 0 7, 53 2 , 9 78 , 1 2 01 , 1 2 02 , and 4 34 6 ; and E. O. 9 39 7 .

PRINCIPAL PURPOSE(S):

To obt ain medical dat a f or det erminat ion of medical f it ness f or enlist ment, induct ion, appoint ment and ret ent ion f or applicant s and members of t he Armed Forces. The informat ion w ill also be used f or medical boards and separat ion of Service members f rom t he Armed Forces.

ROUTINE USE(S):

None.

DISCLOSURE:

Volunt ary; how ever, f ailure by an applicant t o provide t he inf ormat ion may result in delay or possible rejection of t he individual' s applicat ion t o ent er t he Armed Forces. For an Armed Forces member, f ailure t o provide t he inf ormat ion may result in t he individual being placed in a non-deployable st at us.

3 . LAST NAME - FIRST NAME - MIDDLE NAME (SUFFIX ) 123 my street Joe, Gerold I.

6 . GRADE 7 . DATE OF BIRTH 8 . AGE

(Y YYYMMDD)

E-5 1974/04/16 1 1 . TOTAL YEARS GOV ERNMENT SERV ICE a. MILITARY b. CIVILIAN 9 yrs 6 yrs 9 . SEX Ft Lewis, WA 98433 1 0 .a. RACIAL CATEGORY

(X one or more)

Black or A f rican A merican Female A merican Indian or A laska Nat ive

Male

Post Office

A sian

1 2 . AGENCY *

(Non-Service Members Only)

Whit e

1 4 .a. RATING OR SPECIALTY

(A viat ors Only)

4 . HOME ADDRESS

(St reet , A part ment Number, Cit y, St at e and ZIP Code)

b. TOTAL FLYING TIME 5 . HOME TELEPHONE NUMBER

(Include A rea Code)

(253) 555-4321 b. ETHNIC CATEGORY

Nat ive Haw aiian or Ot her Pacif ic Islander Hispanic/ Lat ino Decline to Respond Not Hispanic/ Lat ino

* 1 3 . ORGANIZATION UNIT AND UIC/CODE * 29 sig bn / WEJGT0 c. LAST SIX MONTHS

Decline

Respond

1 5 .a. SERV ICE

b. COMPONENT

c. PURPOSE OF EX AMINATION

A rmy Coast Guard

A ct ive Dut y Enlist ment

Medical Board Ot her

Navy Marine Corps A ir Force

* *

Reserve Nat ional Guard Commission Ret ent ion Separat ion Ret irement U.S. Service A cademy ROTC Sch olarship Program

CLINICAL EVALUATION

(Check each it em in appr opriat e column. Ent er " NE" if not evaluat ed.)

Nor mal Ab norm NE 1 6 . NAME OF EX AMINING LOCATION, AND ADDRESS

(Include ZIP Code)

MAMC Tacoma, WA 98433

4 4 . NOTES:

(Describe every abno rmalit y in det ail. Ent er pert inent it em number bef o re each commen t . Cont inue i n it em 7 3 and use addit ional

1 7 .

Head, f ace, neck, and scalp

sheet s if necessary.)

1 8 .

Nose 1 9 . Sinuses

2 0 .

Mout h and t hroat

2 1 .

Ears - General

(Int . and ext . canals/A udi t ory acuit y under it em 7 1 )

2 2 . Drums

(Perf orat ion)

2 3 .

Eyes - General

(V isual acuit y and r ef ract ion under it em s 6 1 - 6 3 )

2 4 .

Opht halmoscopic

2 5 .

Pupils

(Equalit y a nd react ion)

2 6 . Ocular mot ilit y

(A ssociat ed parallel movement s, nyst agmus)

2 7 .

Heart

(Thrust , size, rhyt hm, sounds)

2 8 .

Lungs and chest

(Include breast s)

2 9 .

V ascular syst em

(V aricosit ies, et c.)

3 0 .

A nus and rect um

(Hemorrhoids, Fist ulae) (Prost at e if indicat ed)

3 1 .

A bdomen a nd viscera

(Include hernia)

3 2 .

Ext ernal genit alia

(Genit ou rinary)

3 3 .

Upper ext remit ies

3 4 .

Low er ext remit ies

(Except f eet )

3 5 .

Feet

(See It em 3 5 Cont inued)

3 6 .

Spine, ot her m usculoskelet al

3 7 .

Ident if ying body marks, scars, t at t oos

3 8 .

Skin, lymphat ics

3 9 .

Neurologic

4 0 .

Psychiat ric

(Specif y an y personalit y deviat ion

)

4 1 .

Pelvic

(Females only)

4 2 .

Endo crine

3 5 . FEET

(Cont inued) (Circle cat egory)

A ccept able Not A ccept able Class

DD FORM 2808 , JAN 2003

(Please explain. Use d ent al f orm if complet ed

by dent ist . If dent al examinat ion not done by dent al of f icer, explain in It em 4 4 .)

Normal A rch Pes Cavus Pes Planus DoD except ion t o SF 88 approved by ICMR, A ugust 3, 2000.

PREV IOUS EDITION IS OBSOLETE.

Mild Moderat e Severe A sympt omat ic Sympt omat ic Page 1 of 3 Pages 70

DD form 2808 Page 2

LAST NAME - FIRST NAME - MIDDLE NAME (SUFFIX ) Joe, Gerold I.

LABORATORY FINDINGS 4 5 . URINALYSIS 4 6 . URINE HCG a. Albumin b. Sugar RESULTS TESTS 4 7 . H/H

HIV SPECIMEN ID LA BEL

4 9 . HIV 5 0 . DRUGS 5 1 . ALCOHOL 5 2 . OTHER a. PA P SMEAR b.

SOCIAL SECURITY NUMBER 555-55-5555 M EASUREM ENTS AND OTHER FINDINGS 5 5 . MIN WGT - MAX WGT MAX BF % 5 6 . TEMPERATURE 4 8 . BLOOD TYPE DRUG TEST SPECIMEN ID LABEL 5 7 . PULSE 5 3 . HEIGHT 5 4 . WEIGHT

lbs.

5 8 . BLOOD PRESSURE a. 1 ST b. 2 ND c. 3 RD 5 9 . RED/GREEN

(A rmy Only)

6 0 . OTHER V ISION TEST

SYS. DIA S. SYS. DIA S.

6 1 . DISTANT V ISION

Right 2 0 / Corr. t o 2 0 / Lef t 2 0 / Corr. t o 2 0 /

6 4 . HETEROPHORIA

(Specif y dist ance)

ES EX SYS. DIA S. R.H.

6 2 . REFRACTION BY AUTOREFRACTION OR MANIFEST

By By S.

CX CX L.H. Prism div.

6 3 . NEAR V ISION

Right 2 0 / Lef t 2 0 / Prism Conv CT Corr. t o 2 0 / Corr. t o 2 0 / NPR by by PD

6 5 . ACCOMMODATION

Right

6 8 . FIELD OF V ISION 7 1 a. AUDIOMETER

Dat e Calibrat ed

(YYYY MMDD)

Right HZ 5 0 0 Lef t Unit Serial Number 1 0 0 0 2 0 0 0 3 0 0 0

6 6 . COLOR V ISION

(Test used and result )

PIP /1 4

6 9 . NIGHT VISION

(Test used and score)

6 7 . DEPTH PERCEPTION

(Test used and score)

AFV T

Uncorrect ed Correct ed 4 0 0 0 6 0 0 0

7 1 b

. Unit Serial Number Dat e Calibrat ed

(YYYY MMDD)

HZ Right 5 0 0 1 0 0 0 2 0 0 0 Lef t Lef t

7 3 . NOTES

(Cont inued)

AND SIGNIFICANT OR INTERV AL HISTORY

(Use addit ional sheet s if necessary.)

7 0 . INTRAOCULAR TENSION

O.D.

O.S.

7 2 a. READING ALOUD TEST

3 0 0 0 4 0 0 0

6 0 0 0

SA T

7 2 b. V ALSALV A

SA T UNSA T UNSA T Page 2 of 3 Pages 71

DD FORM 2808 , JAN 2003

DD form 2808 Page 3

LAST NAME - FIRST NAME - MIDDLE NAME (SUFFIX ) 7 4 .a. EX AMINEE/APPLICANT

(check one)

IS QUA LIFIED FOR SERV ICE IS NOT QUA LIFIED FOR SERV ICE

b. PHYSICAL PROFILE

P U L

SOCIAL SECURITY NUMBER Joe, Gerold I.

555-55-5555 7 5 . I have been advised of my disqualifying condition.

a. SIGNATURE OF EX AMINEE b. DATE

(YYYYMMDD)

H E S X PROFILER INITIA LS DA TE

(YYYY MMDD)

7 6 . SIGNIFICANT OR DISQUALIFYING DEFECTS

ITEM NO.

MEDICA L CONDITION/DIAGNOSIS ICD CODE PROFILE SERIA L RBJ DA TE

(YYYYMMDD)

QUA LI FIED DIS QUA LI FIED EX A MINER INITIA LS WA IV ER RECEIV ED SERV ICE DA TE

(YYYYMMD D)

7 7 . SUMMARY OF DEFECTS AND DIAGNOSES

(List diagnoses w it h it em numbers) (Use addit ional sheet s if necessary.)

7 8 . RECOMMENDATIONS - FURTHER SPECIALIST EX AMINATIONS INDICATED

(Specif y) (Use addit ional sheet s if necessary.)

7 9 . MEPS WORKLOAD

(For MEPS use only)

WKID ST DA TE

(YYYYMMDD)

INITIA L WKID

8 0 . MEDICAL INSPECTION DATE

HT WT % BF MA X WT HCG QUA L DISQ ST DA TE

(YYYYMMDD)

INITIA L PHYSICIA N' S SIGNA TURE

8 1 .a. TYPED OR PRINTED NAME OF PHYSICIAN OR EX AMINER 8 2 .a. TYPED OR PRINTED NAME OF PHYSICIAN OR EX AMINER 8 3 .a. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN

(Indicat e w hich)

b. SIGNATURE b. SIGNATURE b. SIGNATURE 8 4 .a. TYPED OR PRINTED NAME OF REV IEWING OFFICER/APPROV ING AUTHORITY b. SIGNATURE 8 5 . This examination has been administratively reviewed for completeness and accuracy.

a. SIGNATURE b. GRADE 8 6 . WAIV ER GRANTED

(If yes, dat e and by w hom)

YES NO DD FORM 2808 , JAN 2003 c. DATE

(YYYY MMDD)

8 7 . NUMBER OF ATTACHED SHEETS

Page 3 of 3 Pages 72

DD form 2807-1 Page 1

Note: Please insure that you mark

ANY

and

ALL

Medical conditions you have had during your military career. The Reviewing Physician will determine if further evaluation of the condition is required

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

Form A p proved OMB No. 0 7 0 4 -0 4 1 3 Expires A ug 3 1 , 2 0 0 3

The public report ing burden f or t his collect ion of inf ormat ion is est imat ed t o average 10 minut es per response, including t he t ime f or reviewing inst ruct ions, searching exist ing data sources, gat hering and maint aining the dat a needed, and complet ing and review ing t he collection of inf ormat ion. Send comment s regarding t his burden est imate or any ot her aspect of t his collect ion of inf ormat ion, including suggest ions f or reducing t he burden, t o Depart ment of Def ense, Washingt on Headquart ers Services, Direct orat e f or Inf ormat ion Operat ions and Report s (0704-0413), 1215 Jef ferson Davis Highw ay, Suit e 1204, A rlingt on, V A 22202-4302. Respondent s should be aw are t hat not w it hst anding any ot her provision of law , no person shall be subject t o any penalty f or f ailing t o comply w ith a collect ion of inf ormat ion if it does not display a current ly valid OMB cont rol number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. RETURN COM PLETED FORM AS INDICATED ON PAGE 2 .

PRIVACY ACT STATEM ENT AUTHORITY:

1 0 USC 5 0 4 , 5 0 5 , 5 0 7 , 5 3 2 , 9 7 8 , 1 2 0 1 , 1 2 0 2 , and 4 3 4 6 ; and E.O. 9 3 9 7 .

PRINCIPAL PURPOSE(S): ROUTINE USE(S): DISCLOSURE:

None.

To obt ain medical dat a f or det erminat ion of medical f it ness f or e nlist ment , induct ion, appoint ment and ret ent ion f or applicant s and members of t he A rmed Forces. The inf ormat ion w ill als o be used f or med ical boards and s eparat ion of Serv ice members f rom t he A rmed Forces.

V olunt ary; ho w ever, f ailure by an applica nt t o provide t he inf ormat io n may result i n delay or pos sible reject io n of t he indiv idual' s applic at ion t o ent er t he A rmed Forces. For an A rmed Forces memb er, f ailure t o provide t he inf ormat i on may resul t in t he ind ividual bein g placed in a non-deploy able st at us.

WARNING:

The inf ormat ion you have given const itut es an off icial st at ement . Federal law provides severe penalt ies (up t o 5 years conf ine ment or a $ 1 0 , 0 0 0 f ine or bot h), t o anyone making a f alse st at ement . If you are select ed for enlist ment , commission, or ent rance int o a commissioning program based on a f alse st atement , you can be t ried by milit ary court s-mart ial or meet an administ rat ive board for discharge and could receive a less than honorable discharge t hat would af f ect your fut ure.

1 . LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX ) Joe, Gerold I.

4 .a. HOME ADDRESS

(St reet , A part ment No., Cit y, St at e, and ZIP Code)

123 my street 2 . SOCIAL SECURITY NUMBER 555-55-5555 3 . TODAY' S DATE

(YYYYM MDD)

01 JAN 04 5 . EX AMINING LOCATION AND ADDRESS

(Include ZIP Code)

Madigan Army Medical Center Ft Lewis, WA 98433 b. HOME TELEPHONE

(Include A rea Code)

X ALL APPLICABLE BOXES: (253) 555-4321 Tacoma, WA 98431 7 .a. POSITION

(Tit le, Grade, Component )

6.a. SERVICE x

A rmy Navy Marine Corps Coast Guard

b. COMPONENT x

A ct ive Dut y

x x

Reserve Nat ional Guard

c. PURPOSE OF EX AMINATION

Enlist ment Commission Ret ent ion A ir Force Separat ion

8 . CURRENT MEDICATIONS

(Prescript i on and Over- t he-count er)

Medical Board Ret irement U.S. Service A cademy Ot her

(Specif y)

ROTC Sch olarship Program

SGT,E-5,AD ARMY b. USUAL OCCUPATION Truck driver

9 . A LLERGIES (Including insect bit es/st ings, f oods, medicine or ot her subst ance)

Advil, Zomig, Vicodin Penicillin, Bee Stings, Peanuts M ark 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: 1 0 .

a. Tuberculosis b. Liv ed w it h some one w ho had t uberculosis c. Coughed up blood d. A st hma or any breat hing problems relat ed t o exercise, w eat her, pollens, et c.

e. Short ness of breat h f . Bronchit is g. Wheezi ng or p roblems w it h w heezing h. Been prescribe d or used an inhaler i. A chronic cough o r cough at night j. Sinusit is

YES NO * * * * * * 1 2 .

(Cont inued)

f . Foot t rouble

(e.g., pain, corns, bun ions, et c.)

g. Impaired use of arms, legs, hands, or f eet h. Sw ollen o r painf ul joint (s) i. K nee t rouble

(e. g. , locking, giving out , pain or ligament injury, et c. )

Any knee or foot surgery including arthroscopy or the use of a scope

t o any bone or joint k .

A ny need t o use correct ive devices such as prost het ic devices, knee brace(s), back support (s), lif t s or ort hot ics, et c .

l. Bone, j oint , or ot h er def ormit y m. Plat e(s), sc rew (s), rod(s) or pin(s) in any bone n. Bro ken bone(s)

(cracked or f ract ured)

YES NO * * ** * * *

k. Hay f ever l. Chronic or f requent colds

1 1

.a. Severe t oot h or gum t rouble

* 1 3

.a. Freque nt indige st ion or heart burn b. St oma ch, liver, in t est inal t rou ble, or ulcer c. Gall b ladder t rouble or gallst ones d. Jaundic e or hepat it is

(liver disease)

b. T hyroid t rouble o r goit er c. Eye disorder or t rouble d. Ear, nose, or t hroat t rouble e. Loss of vision in eit her eye f . Worn cont act lenses or glasses g. A h earing loss or w ear a hearing aid h.

Surgery t o co rrect vision

(RK, PRK, LA SIK, et c.)

* * **

e. Rup t ure/hernia f . Rect al disea se, hemorrhoids or b lood f rom t he rect um g. Skin diseases

(e.g. acne, eczema, psoriasis, et c.)

h. Fr equent or painf ul urinat ion i. High or low blo od sugar j. Kidney st one o r blood in urine k. S ugar or prot ein in urine l. Sexually t ransmit t ed disease

(syphilis, gonorrhea, chlamydia, genit al

warts, herpes, etc.) 1 2

.a. Painf ul should er, elbow or w rist

(e. g. pain, dislocat ion, et c. )

b. A rt hrit is, rheumat ism, or bursit is c. Rec urrent back pain or any back problem d. Numbne ss or t ingling e. Loss of f inger or t oe

DD FORM 2807 -1, JUL 2001 * * * 1 4

.a. A dverse react ion t o serum, f ood, insect st ings or medicine

b. Recent u nexplained gain or los s of w eight c. Cur rent ly in g ood healt h

(If no, explain in It em 2 9 on Page 2 .)

d. Tumor, grow t h, cyst , or cancer DoD except ion t o SF 93 approved by ICMR, A ugust 3, 2000.

PREV IOUS EDITION MA Y BE USED UNTIL FEBRUA RY 1 , 2 0 0 2 .

* *

USAPA V1.00

* * * * *

DD form 2807-1 Page 2

LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX ) SOCIAL SECURITY NUMBER Joe, Gerold I.

M ark each item "YES" or "NO". Every item marked "YES" must be fully explained in Item 2 9 below.

555-55-5555 HAVE YOU EVER HAD OR DO YOU NOW HAVE: YES NO YES NO 1 5 .

a. Dizziness or f aint ing spells b. Frequent or severe headache c. A he ad injury, memory loss or amnesia d. Paralysis e. Seizures , convulsions, e pilepsy or f it s f . Car, t rain, sea, or air sickness g. A per iod of uncon sciousness o r concussion h. Me ningit is, encephal it is, or ot her neu rological problems

1 6 .

a. Rheumat ic f ever b. Prolo nged bl eeding

(as af t er an injury or toot h ext ract ion, et c. )

c . Pain or pr es s ure in t he c hes t d. Palpi t at ion, pou nding heart or abnorma l heart beat e. Heart t rouble or murmur f . Hi gh or low bl ood pressure

1 7 .

a. Nervous t rouble of any sort

(anxiet y or panic at t acks)

b. Habit ual st ammering or st ut t ering c. Loss o f memory or amn esia, or neurol ogical sympt oms d. Fre quent t roub le sleeping e. Received co unseling of any t ype f . Depression or excessive w orry g. Been evalu at ed or t reat ed f or a ment al condit ion h. A t t empt ed suicide i. Use d illegal d rugs or abu sed prescri pt ion drugs

1 8 . FEMALES ONLY. H ave you e ver had or do you now have:

a. Treat ment f or a gynecologica l (f emale) disorder b. A change of menst rual pat t ern c. A ny abn ormal PA P smears d. First day of last menst rual period

(YYYYM MDD)

e. Dat e of last PA P smear

(YYYY MMDD) st at us.)

* * * * ** * * * * * * * * * 1 9

. Have you be en ref used employmen t or been unable t o hold a job or st ay in school because of : a. Sensit ivit y t o chemicals, dust , sunlight , et c.

b. Inabilit y t o per f orm cert ain mot ions c. Inabilit y t o st and, sit , kneel, lie dow n, et c.

d. Ot her medical reasons

2 0

. Have you ever been t reat e d in an Emer gency Room?

(If yes, f or w hat ?)

2 1

. Have you ever been a pat ie nt in any t ype of hospit al?

address of hospit al.) (If yes, specif y w hen , w here, w hy, a nd name of doct or and complet e

2 2

. Have you ev er had, or have you be en advised t o have any operat ion s or surgery?

(If yes, describe and give age at w hich occurred.) (If yes, give reasons.)

2 3

. Have you ever h ad any illness or injury ot h er t han t hose already not ed?

(If yes, specif y w hen, w here, and give det ails.)

2 4

. Have you consult ed or been t reat ed by clinics, physicians, healers, or ot her pract it io ners w it hin t he past 5 years f or ot her t han minor illnesses?

(If yes, give complet e address of doct or, hospit al, clini c, and det ails.)

2 5

. Have you ever been reject ed f or milit ary service f or any reason?

(If yes, give dat e and reason f or reject ion.)

2 6

. Have you ever been discharged f rom milit ary service f or any reason?

(If yes, give dat e, reason, and t ype of discharge; w het her h onorable, ot her t han hon orable, f or unf it ness or unsuit abilit y.)

2 7

. Have you e ver received , is t here p ending, or h ave you ever applie d f or pensio n or compens at ion f or an y disabilit y or injury?

(If yes, specif y w hat kind, grant ed by w hom, and w h at amount , w hen, w hy.)

2 8

. Have you ever been denied li f e insurance?

* 2 9 . EX PLANATION OF " YES" ANSWER(S)

(Describe answ er(s), give d at e(s) of problem, name of doct or(s) and/or ho spit al(s), t reat ment gi ven and current medical

* * * * * * * * * * * 10k , Seasonal allergies since I was 10 years old. (ongoing) 12a , Wrist pain is from lifting heavy rounds. Pain started on 12Jun03 (Resolved) Please Place “ongoing” or “resolved” next to each explanation.

12c , Back pain started from lifting ammunition boxes into tanks. Pain is a 6 out of ten on most days (ongoing) NOTE: HAND TO THE DOCTOR OR NURSE, OR IF M AILED M ARK ENVELOPE "TO BE OPENED BY M EDICAL PERSONNEL ONLY. " DD FORM 2807 -1, JUL 2001

Page 2 of 3 Pages USAPA V1.00

Standar d For m 507 SF 507 extra room for more explanations of yes answers

CLINICAL RECORD Report on or Continuation of S.F.

(Strike out one line) (Specify type of examination or data) (Sign and date)

16c , Chest pains come and go for unknown reasons (ongoing) 20 , I was seen in the ER on 08OCT02 for a rash that covered half my body from my waist down. It cleared up two months later. (resolved)

PATIENT'S IDENTIFICATION

(Continue on reverse side) (For typed or written entries give: Name - last, first, middle; grade; date; hospital or medical facility)

REPORT ON

or CONTINUATION OF Standard Form 507

GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTE ON MEDICAL RECORDS FPMR 101-11-80-6-8 OCTOBER 1975 USAPPC V1.00

DD form 2807-1 Page 3

LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX ) SOCIAL SECURITY NUMBER Joe, Gerold I.

555-55-5555 3 0 . EXAM INER'S SUM M ARY AND ELABORATION OF ALL PERTINENT DATA

(Physician/ practit ioner shall comment on all posit ive answers in quest ions 10 - 29 . Physician/ pract it ioner may develop by interview any addit ional medical hist ory deemed import ant , and record any signif icant f indings here. )

a. COMMENTS

Please DO NOT Write on this page.

b. TYPED OR PRINT ED NAME OF EX AMINER

(Last , First , Middle Init ial)

c. SIGNATURE DD FORM 2807 -1, JUL 2001 d. DATE SIGNED

(YY YYMMDD)

Page 3 of 3 Pages USAPA V1.00