Fillable Printable Medical Record - Supplemental Medical Data

Medical Record - Supplemental Medical Data

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA

For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General.

REPORT TITLE

OTSG APPROVED

(Date)

(YYYYMMDD)

(Continue on reverse)

PREPARED BY (Signature & Title)

DEPARTMENT/SERVICE/CLINIC

DATE (YYYYMMDD)

PATIENT'S IDENTIFICATION (For typed or written entries give: Name last,

first, middle; grade; date; hospital or medical facility)

HISTORY/PHYSICAL

OTHER EXAMINATION

OR EVALUATION

DIAGNOSTIC STUDIES

TREATMENT

FLOW CHART

OTHER

(Specify)

DA FORM 4700, FEB 2003

EDITION OF MAY 78 IS OBSOLETE.

APD LC v1.01ES