Fillable Printable Medical And Dental Preparation For Oversea Movement
Fillable Printable Medical And Dental Preparation For Oversea Movement
Medical And Dental Preparation For Oversea Movement
8. PROJECTED DUTY MOS OR AOC (9 Position Code)
1. TO
3. NAME (Last, Middle, First)
4. SSN
2. FROM
5A. GRADE OR RANK 5B. PMOS OR AOC
6. PRESENT UNIT OF ASSIGNMENT
7. PROJECTED UNIT OF ASSIGNMENT (Include location/country)
9. ANTICIPATED DATE OF LOSS
12. LIST ANY OTHER SPECIAL MEDICAL OR DENTAL INSTRUCTIONS CONTAINED IN THE ASSIGNMENT INSTRUCTIONS
13A. NAME OF MPD/PSC REPRESENTATIVE
C. SIGNATURE
B. TITLE
D. GRADE
E. DATE (YYYYMMDD)
MEDICAL AND DENTAL PREPARATION FOR OVERSEAS MOVEMENT
For use of this form, see AR 600-8-11; the proponent agency is DCS, G-1.
DA FORM 4036, MAR 2007
PREVIOUS EDITIONS ARE OBSOLETE
APD LC v1.01ES
Page 1 of 2
PRIVACY ACT STATEMENT
11. IF ANSWER TO ITEM 10 IS "YES" AND IF MEMBER IS REQUESTING FAMILY TRAVEL, ALL FAMILY MEMBERS WILL BE SCREENED BY THE LOCAL
NAME NAME
10. IS MEMBER BEING ASSIGNED TO AN
Title 10, USC, Sections 3010, 8012 and 5031, and Title 5, USC, Section 301.
Authority:
Principal Purpose:
Routine Uses:
Disclosure:
Yes
No
Information is required on all soldiers being reassigned overseas to determine if they meet medical and dental
standards for such assignment.
(1) For personnel service support; and (2) Information is primarily obtained from review of records unless assignment
is to be an isolated area which requires evaluation and personal interview.
Disclosure of information is voluntary. If family members are required to complete medical and dental evaluation
and personal interview, but refuse to do so, they will not be permitted to accompany the soldier to the oversea
assignment.
ISOLATED AREA AS DEFINED BY AR 40-501,
PARA 5-13C?
MEDICAL TREATMENT FACILITY FOR SPECIAL MEDICAL AND FUNCTIONAL NEEDS. ENTER NAMES OF ALL ACCOMPANYING FAMILY MEMBERS, OTHERWISE
ENTER N/A.
23A.
C.
B. TITLE
D. GRADE
E. DATE (YYYYMMDD)
27A. NAME OF DENTAL OFFICER
C. SIGNATURE
B. TITLE
D. GRADE
E. DATE (YYYYMMDD)
DA FORM 4036, MAR 2007
Page 2 of 2
APD LC v1.01ES
MEDICAL STATUS
14A. PHYSICAL PROFILE SERIAL CODE B. PHYSICAL CATEGORY CODE
C. MEDICAL RECORDS REVEAL THE FOLLOWING ASSIGNMENT
ITEMN/A
15A. Does the member meet the medical fitness
standards outlined in AR 40-501? (If "no" explain briefly.)
B. IF CONDITION IS TEMPORARY, EXPECTED DATE
MEMBER WILL BE ELIGIBLE FOR ASSIGNMENT
B. DATE, TIME AND LOCATION OF APPOINTMENT
B. IF "YES", EXPECTED DATE OF DELIVERY
B. IF "YES", INDICATE DATE, TIME, AND LOCATION OF
DATE, TIME AND LOCATION OF APPOINTMENT, IF NEEDED
APPOINTMENT
B. IF "YES", INDICATE DATE, TIME, AND LOCATION OF
APPOINTMENT
B. IF "YES", INDICATE DATE THE MEMBER ENTERED
THE REHABILITATION PROGRAM
22. Medical Records Indicate the Member Requires the Following (Check those appropriate)
ITEMMISSINGHASREQUIRES
A Two pairs of spectacles
B. Protective mask spectacle
C. Two hearing aids
D. Medical warning tag
DENTAL STATUS (Complete only if Item 10 is checked "Yes" or if required by item 12.)
(PULHES)
16A. Has member completed HIV screening?
17A. Is the member pregnant?
18A. All active duty and reserve personnel of PCS
19A. Does the member require remedial medical care?
20A. Is the member currently undergoing alcohol or
drug abuse rehabilitation?
21A. If item 10 is checked "yes", can the member be
NAME OF MEDICAL OFFICER
SIGNATURE
24A. Is the member dentally qualified?
25A. Does the member require remedial dental
care?
26A. If item 10 is checked "yes", can the member
YES NO
YES NO
B. IF "NO", BRIEFLY EXPLAIN. IF CONDITION IS TEMPORARY, EXPECTED
DATE THE MEMBER WILL BE ELIGIBLE FOR ASSIGNMENT
B. IF "YES", INDICATE DATE, TIME, AND LOCATION OF APPOINTMENT
B. IF "YES", THE MEMBER (and family members, if applicable) MUST BE
SCHEDULED FOR A FOLLOW-UP EVALUATION OF MEDICAL STATUS WITHIN
30 CALENDAR DAYS OF THE ANTICIPATED DATE OF LOSS (Item 9). INDICATE
DATE, TIME, AND LOCATION OF APPOINTMENT(S)
B. IF "YES", THE MEMBER (and family members, if
applicable) MUST BE SCHEDULED FOR A FOLLOW-UP
EVALUATION OF MEDICAL STATUS WITHIN 30 CALENDAR
DAYS OF THE ANTICIPATED DATE OF LOSS (Item 9).
INDICATE DATE, TIME AND LOCATION OF APPOINTMENT(S)
Complete the medical and dental status portions below, return the original and one copy to the MDP/PSC within 21 calendar days of the
date shown in item 13E, and forward one copy to the address in item 6.
LIMITATIONS
assigned to an area where medical facilities are limited or
nonexistent?
assignment to Korea will be vaccinated with hepatitis
B vaccine. Does the member require immunization?
insert
be assigned to an area where dental facilities are
limited or nonexistent?
