Fillable Printable DD Form 2807-1

What is a DD Form 2807-1 ?

A DD Form 2807-1 is a Department of Defense form which is used to gather medical information for applicants who need to accept military service. It's used by MEPS during the MEPS medical examination. Military physicians determine if an applicant can be accepted or should be disqualified on medical grounds with the help of it. Sign and fill DD Form 2807-1 Online at HandyPDF.

Fillable Printable DD Form 2807-1

What is a DD Form 2807-1 ?

DD Form 2807-1

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. If you are selected for enlistment, commission, or entrance into a commissioning program

based on a false statement, you can be tried by military courts-martial or meet an administrative board for discharge and could receive a less than

honorable discharge that would affect your future.

REPORT OF MEDICAL HISTORY

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

X ALL APPLICABLE BOXES:

OMB No. 0704-0413

OMB approval expires

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM AS INDICATED ON PAGE 2.

1. LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX) 2. SOCIAL SECURITY NUMBER 3. TODAY'S DATE (YYYYMMDD)

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

b. HOME TELEPHONE (Include Area Code)

5. EXAMINING LOCATION AND ADDRESS (Include ZIP Code)

Army

Navy

Marine Corps

Air Force

Regular

Reserve

National Guard

c. PURPOSE OF EXAMINATION

Enlistment

Commission

Retention

Separation

Medical Board

Retirement

U.S. Service Academy

ROTC Scholarship Program

Other (Specify)

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

b. USUAL OCCUPATION

8. CURRENT MEDICATIONS (Prescription and Over-the-counter) 9. ALLERGIES (Including insect bites/stings, foods, medicine or other substance)

HAVE YOU EVER HAD OR DO YOU NOW HAVE: YES NO

c. Coughed up blood

Asthma or any breathing problems related to exercise, weather,

pollens, etc.

e. Shortness of breath

f. Bronchitis

YES NO

11.a. Severe tooth or gum trouble

b. Thyroid trouble or goiter

c. Eye disorder or trouble

d. Ear, nose, or throat trouble

e. Loss of vision in either eye

f. Worn contact lenses or glasses

g. A hearing loss or wear a hearing aid

c. Recurrent back pain or any back problem

d. Numbness or tingling

e. Loss of finger or toe

b. Recent unexplained gain or loss of weight

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

d. Tumor, growth, cyst, or cancer

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

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

l. Bone, joint, or other deformity

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

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

DD FORM 2807-1, AUG 2011

DoD exception to SF 93 approved by ICMR, August 3, 2000.

PREVIOUS EDITION IS OBSOLETE.

13.a. Frequent indigestion or heartburn

b. Stomach, liver, intestinal trouble, or ulcer

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

Sexually transmitted disease (syphilis, gonorrhea, chlamydia, genital

warts, herpes, etc.)

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

to any bone or joint

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

b. Arthritis, rheumatism, or bursitis

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

j. Sinusitis

k. Hay fever

l. Chronic or frequent colds

g. Wheezing or problems with wheezing

i. A chronic cough or cough at night

h. Been prescribed or used an inhaler

10.a. Tuberculosis

b. Lived with someone who had tuberculosis

Page 1 of 3 Pages

c. Gall bladder trouble or gallstones

d. Jaundice or hepatitis (liver disease)

e. Rupture/hernia

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

h. Frequent or painful urination

i. High or low blood sugar

j. Kidney stone or blood in urine

k. Sugar or protein in urine

f. Rectal disease, hemorrhoids or blood from the rectum

6.a. SERVICE

12. (Continued)

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

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

h. Swollen or painful joint(s)

i. Knee trouble

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

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 136, DoD Instruction 6130.03, and E.O. 9397, as amended (SSN).

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. Completed forms are covered by recruiting, medical evaluation board, and official military personnel file SORNs

maintained by each of the Services.

ROUTINE USE(S): The Blanket Routine Uses found at http://privacy.defense.gov/blanket_uses.shtml

apply to this collection.

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.

b. COMPONENT

Coast

Guard

Mark each item "YES" or "NO". Every item marked "YES" must be fully explained in Item 29 on Page 2.

Adobe Professional 8.0

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, Executive Services Directorate, Information Management Division, 1155 Defense

Pentagon, Washington, DC 20301-1155 (0704-0413). 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.

Aug 31, 2014

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

b. Inability to perform certain motions

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

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

19. Have you been refused employment or been unable to hold a job

or stay in school because of:

28. Have you ever been denied life insurance?

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.)

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.)

20. Have you ever been treated in an Emergency Room?

(If yes, for what?)

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.)

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.)

23. Have you ever had any illness or injury other than those

already noted? (If yes, specify when, where, and give details.)

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, AUG 2011

Page 2 of 3 Pages

LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX) SOCIAL SECURITY NUMBER

b. Habitual stammering or stuttering

c. Loss of memory or amnesia, or neurological symptoms

17.a. Nervous trouble of any sort (anxiety or panic attacks)

e. Received counseling of any type

d. Frequent trouble sleeping

g. Been evaluated or treated for a mental condition

h. Attempted suicide

i. Used illegal drugs or abused prescription drugs

f. Depression or excessive worry

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)

e. Date of last PAP smear (YYYYMMDD)

YES NO YES NO

15.a. Dizziness or fainting spells

b. Frequent or severe headache

c. A head injury, memory loss or amnesia

d. Paralysis

e. Seizures, convulsions, epilepsy or fits

f. Car, train, sea, or air sickness

g. A period of unconsciousness or concussion

h. Meningitis, encephalitis, or other neurological problems

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

b. Prolonged bleeding (as after an injury or tooth extraction, etc.)

16.a. Rheumatic fever

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:

a. COMMENTS

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

d. DATE SIGNED

(YYYYMMDD)

c. SIGNATURE

DD FORM 2807-1, AUG 2011

Page 3 of 3 Pages

LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX) SOCIAL SECURITY NUMBER

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.)

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