Medical Report

REPORT FOR MEDICAL EXAMINATION

PRIVACY ACT STATEMENT

AUTHORITY: 10 USC 504, 505, 507, 532, 978, 1201, 1202, AND 4346; AND E.O. 9397.

PRINCIPAL PURPOSE(S): TO OBTAIN MEDICAL DATA FOR DETERMINATION OF MEDICAL FITNESS FOR ENLISTMENT, INDUCTION, APPOINTMENT AND RETENTION FOR APPLICANTS AND MEMBERS OF THE ARMED FORCES. THE INFORMATION WILL ALSO BE USED FOR MEDICAL BOARDS AND SEPARATION OF SERVICE MEMBERS FROM THE ARMED FORCES.

ROUTINE USE(S): NONE

DISCLOSURE: VOLUNTARY; HOWEVER, FAILURE BY AN APPLICANT TO PROVIDE THE INFORMATION MAY RESULT IN DELAY OR POSSIBLE REJECTION OF THE INDIVIDUAL’S APPLICATION FOR LEAVE AND PASS REQUEST. FOR AN ARMED FORCES MEMBER, FAILURE TO PROVIDE THE INFORMATION MAY RESULT PENDING OF LEAVE AND PASS REQUEST

APPLY FOR MEDICAL SCAN

MEDICAL FORM

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Name

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Grade

Date of Birth

Age

Selected Value: 0

Sex

RACIAL CATEGORY

ETHNIC CATEGORY

GOVERNMENT SERVICE

MILITARY
CIVILIAN

AGENCY (Non-Service Members Only)

ORGANIZATION UNIT AND UIC/CODE

RATING OR SPECIALTY (Aviators Only)

TOTAL FLYING TIME

LAST SIX MONTHS

SERVICE

COMPONENT

PURPOSE OF EXAMINATION

NAME OF EXAMINING LOCATION, AND ADDRESS

Reason For Medical Scan