DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)
REPORT OF MEDICAL EXAMINATION
(Please read Privacy Act Statement before completing this form.)
OMB No. 0704-0396
OMB approval expires
Nov 30, 2009
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO DODMERB/DR, 8034
EDGERTON DRIVE, SUITE 132, USAF ACADEMY CO 80840-2200.
1. DATE OF EXAMINATION (YYYYMMDD) 2. NAME (Last, First, Middle Initial) 3. SOCIAL SECURITY ACCOUNT NUMBER
APPLICANT DATA
4. DATE OF BIRTH (YYYYMMDD) 5. AGE 6. SEX 7. RACE (Ethnic Group/Medically Significant)
a. APPLICANT MAILING ADDRESS (Include ZIP Code)
9. STATUS (X one) 10. EXAMINER ADDRESS AND FACILITY NUMBER.
PRIVACY ACT STATEMENT
AUTHORITY: Title 10, USC 133, 3012, 5031, 8013, and Executive Order 9397.
PRINCIPAL PURPOSE: To determine medical acceptability or update a medical file as part of the
application process to a United States Service Academy, Reserve Officer Training Corps (ROTC)
Scholarship Program, or the Uniformed Services University of the Health Sciences (USUHS).
ROUTINE USES: This information may be disclosed to any U.S. Government agency requiring the
information to complete applications to their organizations.
DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection
process and hamper your candidacy. Use of the Social Security Account Number (SSN) is used for
positive identification of records.
MEASUREMENTS
11. HEIGHT (to nearest 1/4 inch)
STANDING SITTING
14. BLOOD PRESSURE
15. AUDIOMETER
500 1000 2000 3000 4000 6000
16. READING ALOUD TEST
SATISFACTORY
UNSATISFACTORY (Explain in Item 57)
12. WEIGHT (to
nearest pound)
13. PULSE
17. DISTANT VISION
RIGHT 20/
LEFT 20/
CORR TO 20/
CORR TO 20/
18. MANIFEST REFRACTION (Required, regardless of corrected/uncorrected
visual acuity)
SPH
SPH
CYL
CYL
AXIS
AXIS
19. NEAR VISION
20/
20/
CORR TO 20/
CORR TO 20/
BY
BY
20. HETEROPHORIA/TROPIA
(Far only)
ESO EXO RH LH
21. COVER TEST
PASS
(Non-Tropia)
FAIL (Tropia)
22. COLOR VISION
PIP (14 plate test only)
MTF and MEPS only:
Perform FALANT if applicant
passes 11 or less on PIP.
Document on DD Form 2489
or SF 600, recording FALANT
results per protocol.
No. Passed
No. Failed
23. DEPTH PERCEPTION
VTA-ND/OVT/AFVT
DPA-V
TITMUS/STEREO FLY (Arcs/second)
TEST USED SCORE
24. NEAR POINT OF CONVERGENCE (in mm)
25. VIVID RED/GREEN (If item 22
passes 9 or less)
PASS FAIL DIPLOPIA SUPPRESSION
LABORATORY
27. URINALYSIS
PROTEIN
SUGAR
BLOOD
NEG
NEG
NEG
T
T
T
1+
1+
1+
2+
2+
2+
3+
3+
3+
4+
4+
4+
NEGATIVE
MICROSCOPIC EXAMINATION (If required) (X one)
POSITIVE (List results)
28. OTHER TESTS (Specify type and results)
DD FORM 2351, MAR 2008
PREVIOUS EDITION IS OBSOLETE.
DoD Exception to SF 88 Approved by GSA/OIRM 4-88
DODMERB USE ONLY
/
SYSTOLIC DIASTOLIC
RIGHT LEFT
500 1000 2000 3000 4000 6000
8. ADDRESS INFORMATION (If left blank will delay processing)
b. ROTC DETACHMENT CODE (If applicable):
26. OCULAR MOTILITY AND BINOCULARITY (RED LENS TEST)
IF FAILED:PASS FAIL
ACTIVE DUTY
CIVILIAN
RESERVE/
GUARD
The public reporting burden for this collection of information is estimated to average 15 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, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon, Washington, DC 20301-1155
(0704-0396). 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.
Adobe Professional 7.0
14.a. REPEAT B/P IF >140/90. REPEAT PULSE IF >99. RECORD RESULTS
HERE:
/
SYSTOLIC DIASTOLIC PULSE
