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REPORT OF MEDICAL ASSESSMENT

REPORT OF MEDICAL ASSESSMENT REPORT CONTROL SYMBOL. DD-HA(AR)1939. PRIVACY ACT STATEMENT. AUTHORITY: PL 103-160, EO 9397. PRINCIPAL PURPOSE: To be used by the MEDICAL Services to provide a comprehensive MEDICAL ASSESSMENT for active and reserve component service members separating or retiring from active duty. ROUTINE USES: A copy of this form will be released to the Department of Veterans Affairs. DISCLOSURE: Voluntary; however, failure to disclose the requested personal information may result in delay in processing any disability claim. SECTION I - TO BE COMPLETED BY SERVICE MEMBER. Any service member who requests a physical examination may have one. 1. NAME (Last, First, Middle) 2. SOCIAL SECURITY NUMBER 3. RANK. 4.

DD FORM 2697, FEB 95 (BACK) SECTION II - TO BE COMPLETED BY INDIVIDUALLY PRIVILEGED HEALTH CARE PROVIDER . This Report of Medical Assessment is to be used by the Medical Services to provide a comprehensive medical assessment for active and reserve component service members separating or retiring from active duty.

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