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Fillable Form DD 2807-1 (2018)

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).

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What is DD Form 2807-1?

DD Form 2807-1 is used by the Department of Defense (DoD) to determine if an applicant seeking to join the military is healthy. It collects the medical history information of the recruit to check his or her medical fitness.

Failure to provide any medical history information in this form may lead to a delay or a potential rejection of the applicant’s application to join the Armed Forces.

How to fill out DD Form 2807-1?

All the information you will provide in DD Form 2807-1 serves as your official statement. Make sure that they are accurate, as any false statement may lead to penalties according to federal laws.

DD Form 2807-1 consists of three pages, answer all applicable items on all pages.

PAGE 1

1. LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX)

Provide your full legal name, following the required format.

2.a. SOCIAL SECURITY NO.

Provide your unique nine-digit Social Security Number.

b. DoD ID NO. (if applicable)

Provide your Department of Defense Identification Number.

3. TODAY’S DATE (YYYYMMDD)

Provide the date when you filled out DD Form 2807-1, following the required format.

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

Provide your complete home address.

b. HOME TELEPHONE (Include Area Code)

Provide your home phone number.

c. EMAIL ADDRESS

Provide your active email address.

5. EXAMINING LOCATION AND ADDRESS (Include ZIP Code)

Provide the complete examining location and address.

For Items 6.a. to 6.c., mark “X” all the applicable boxes.

6.a. SERVICE

Select “Army,” “Navy,” “Marine Corps,” “Air Force,” or “Coast Guard.”

b. COMPONENT

Select “Regular,” “Reserve,” or “National Guard.”

c. Purpose of Examination

Select “Retention,” “Separation,” “Medical Board,” “Retirement,” or “Other.” Specify the purpose for “Other.”

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

Provide your specific position, including your title, grade, and component.

b. USUAL OCCUPATION

Provide your usual occupation.

8. CURRENT MEDICATIONS (Prescription and Over-the-counter)

Provide the current medications you are taking.

9. ALLERGIES (Including insect bites/stings, foods, medicine, or other substance)

Provide all the allergies you have.

For Items 10.a. to 28, mark an item “Yes” if you ever had or now have it or “No” if you had not For every item marked “Yes,” provide the explanation in the space provided in Item 29.

10.a. Tuberculosis

b. Lived with someone who had tuberculosis

c. Coughed up blood

d. Asthma or any breathing problems related to exercise, weather, pollens, etc.

e. Shortness of breath

f. Bronchitis

g. Wheezing or problems with wheezing

h. Been prescribed or used an inhaler

i. A chronic cough or cough at night

j. Sinusitis

k. Hay fever

l. Chronic or frequent colds

11.a. Severe tooth or gum problem

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 add

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

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

b. Arthritis, rheumatism, or bursitis

c. Recurrent back pain or any back problem

d. Numbness or tingling

e. Loss of finger or toe

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.)

j. Any knee or foot surgery including arthroscopy or the use of a scope to any bone or joint

k. 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)

13.a. Frequent indigestion or heartburn

b. Stomach, liver, intestinal trouble, or ulcer

c. Gall bladder trouble or gallstones

d. Jaundice or hepatitis (liver disease)

e. Rupture/hernia

f. Rectal disease, hemorrhoids, or blood from the rectum

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

l. Sexually transmitted disease (syphilis, gonorrhea, chlamydia, genital warts, herpes, etc.)

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

b. Recent unexplained gain or loss of weight

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

d. Tumor, growth, cyst, or cancer

PAGE 2

LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX)

Provide your full legal name, following the required format.

SOCIAL SECURITY NUMBER

Provide your unique nine-digit Social Security Number.

DoD ID NUMBER (if applicable)

Provide your Department of Defense Identification Number.

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

16.a. Rheumatic fever

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

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

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

b. Habitual stammering or stuttering

c. Loss of memory or amnesia, or neurological symptoms

d. Frequent trouble sleeping

e. Received counseling of any type

f. Depression or excessive worry

g. Been evaluated or treated for a mental health condition

h. Attempted suicide

i. Used illegal drugs or abused prescription drugs

Choices under Item 18 are for females only.

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)

Provide the date in YYYY-MM-DD format.

e. Date of last PAP smear (YYYYMMDD)

Provide the date in YYYY-MM-DD format.

19. Have you ever been refused employment or been unable to hold a job or stay in school because of:

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.)

20. Have you ever been treated in an Emergency Room? (If yes, for what?)

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.)

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.)

23. Have you ever had any illness or injury other than those already noted? (If yes, specify when, where, and give details.)

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 or 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, and why.)

28. Have you ever been denied life insurance?

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.)

For every item that you answered “Yes,” provide here the explanation.

PAGE 3

LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX)

Provide your full legal name, following the required format.

SOCIAL SECURITY NUMBER

Provide your unique nine-digit Social Security Number.

DoD ID NUMBER (if applicable)

Provide your Department of Defense Identification Number.

30. EXAMINER’S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician/practitioner shall comment on all positive answer in questions 10-29. Physician/practitioner may develop by interview any additional medical history deemed important, and record any significant findings here.

a. COMMENTS

This item is for the physician or medical practitioner.

b. TYPED OR PRINTED NAME OF EXAMINER (last, FIrst, Middle Initial)

Provide the full legal name of the examiner, following the required format.

c. SIGNATURE

Sign DD Form 2807-1

d. DATE SIGNED (YYYYMMDD)

Provide the date when you signed DD Form 2807-1, following the required format.

FILL ONLINE

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