POST-DEPLOYMENT HEALTH REASSESSMENT (PDHRA)

1 POST-DEPLOYMENT HEALTH REASSESSMENT (PDHRA)Authority: 10 136 Chapter 55. 1074f, 3013, 5013, 8013 and 9397 Principal Purpose: To assess your state of HEALTH after deployment in support of military operations and to assist military healthcare providers,including behavioral HEALTH providers, in identifying present and future medical care needs you may have. The information you provide may result in areferral for additional healthcare that may include behavioral Use: To other Federal and State agencies and civilian healthcare providers as necessary in order to provide necessary medical care andtreatment. Responses may be used to guide possible : Disclosure is : Please read each question completely and carefully before making your selections.

2 Provide a response foreach question. If you do not understand a question, ask the administrator. Please respond based on your MOST NameToday's Date (dd/mm/yyyy)First NameMISocial Security NumberCurrent Unit of AssignmentDOB (dd/mm/yyyy)GenderService BranchStatus Prior to DeploymentLocation of OperationDD FORM 2900, JUN 2005 MaleFemaleAir ForceArmyCoast GuardMarine CorpsNavyOtherActive DutySelected Reserves - Reserve - UnitSelected Reserves - Reserve - AGRS elected Reserves - Reserve - IMAE uropeSW Asia - other34 South AmericaAustraliaAfrica12 Date arrived theater (mm/yyyy)Date departed theater (mm/yyyy)Pay GradeE1E2E3E4E5E6E8E7E9O01O02O03O04O05O0 6O07O08O09O10W1W2W3W4W5 OtherNorth AmericaOther.

3 Since return from deployment I have:KuwaitQatarAfghanistanBosnia/Kosovo On a shipIraqNever MarriedMarriedSeparatedDivorcedWidowedAS D(HA) APPROVED 3334833348 Marital StatusSelected Reserves - National Guard - UnitSelected Reserves - National Guard - AGRR eady Reserves - IRRR eady Reserves - INGC ivilian Government EmployeeOtherRetired from Military ServiceMaintained/returned to previous statusTransitioned to Ready Reserves:Transitioned to Selected Reserves:Separated from Military ServiceCurrent Contact Information:Phone:Cell:DSN:Email:Address :Current Assignment LocationPoint of Contact who can always reach you:Name:Phone:Email:Mailing Address:5 ormoreTotal Deployments in Past 5 Years:OIF34125 ormoreOEF34125 ormoreOtherDD FORM 2900, JUN 2005333481.

4 Overall, how would you rate your HEALTH during the PAST MONTH?PoorFairGoodVery GoodExcellent2. Compared to before your most recent deployment, how would you rate your HEALTH in general now?Much better now than before I deployedSomewhat better now than before I deployedAbout the same as before I deployedSomewhat worse now than before I deployedMuch worse now than before I deployed3. Since you returned from deployment, about how many times have you seen a healthcare provider for any reason, such as in sick call, emergency room, primary care, family doctor, or mental HEALTH provider?Over 6 visits4-5 visits2-3 visits1 visitNo visitsYesNo4.

5 Since you returned from deployment, have you been hospitalized?YesNo5. During your deployment, were you wounded, injured, assaulted or otherwise physically hurt? If NO, skip to Question IF YES, are you still having problems related to this wound, assault, or injury?YesNoUnsure IF NO, skip to Question Other than wounds or injuries, do you currently have a HEALTH concern or condition that you feel is related to your deployment?YesNoUnsure6a. IF YES, please mark the item(s) that best describe your deployment-related condition or concern:Chronic coughRunny noseFeverWeaknessHeadachesSwollen, stiff or painful jointsBack painMuscle achesNumbness or tingling in hands or feetSkin diseases or rashesRedness of eyes with tearingDimming of vision, like the lights were going outChest pain or pressureDizziness, fainting, light headednessDifficulty breathingProblems sleeping or still feeling tired after sleepingDifficulty rememberingDiarrhea, vomiting, or frequent indigestionIncreased irritabilityTaking more risks such as driving fasterRinging of the earsOther:YesNo7.

6 Do you have any persistent major concerns regarding the HEALTH effects of something you believe you may have been exposed to or encountered while deployed? IF NO, skip to Question IF YES, please mark the item(s) that best describe your concern:DEET insect repellent applied to skinPesticide-treated uniformsEnvironmental pesticides (like area fogging)Flea or tick collarsPesticide stripsSmoke from oil fireSmoke from burning trash or fecesVehicle or truck exhaust fumesTent heater smokeJP8 or other fuelsFog oils ( smoke screen)SolventsPaintsRadiationRadar/micr owavesLasersLoud noisesExcessive vibrationIndustrial pollutionSand/dustBlast or motor vehicle accidentDepleted Uranium (if yes, explain)Other:8.

7 Since return from your deployment, have you had serious conflicts with your spouse, family members, close friends, or at work that continue to cause you worry or concern?YesNoUnsure11. Over the PAST MONTH, have you been bothered by the following problems? a. Little interest or pleasure in doing things b. Feeling down, depressed, or hopeless9. Have you had any experience that was so frightening, horrible, or upsetting that, IN THE PAST MONTH, you ..a. Have had any nightmares about it or thought about it when you did not want tob. Tried hard not to think about it or went out of your way to avoid situations that remind you of itc.

8 Were constantly on guard, watchful, or easily startledd. Felt numb or detached from others, activities, or your surroundingsDD FORM 2900, JUN 200533348 YesNoYesNoYesNoYesNo10. a. In the PAST MONTH, did you use alcohol more than you meant to?YesNo b. In the PAST MONTH, have you felt that you wanted to or needed to cut down on your drinking?YesNo12. If you checked off any problems or concerns on this questionnaire, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?Not difficult at allSomewhat difficultVery difficultExtremely difficult13. Would you like to schedule a visit with a healthcare provider to further discuss your HEALTH concern(s)?

9 YesNo14. Are you currently interested in receiving information or assistance for a stress, emotional or alcohol concern?YesNo15. Are you currently interested in receiving assistance for a family or relationship concern?YesNo16. Would you like to schedule a visit with a chaplain or a community support counselor?YesNoNotat allFew orseveraldaysMore thanhalf thedaysNearlyeverydayProvider Review and InterviewSERVICE MEMBER'S SOCIAL SECURITY #Confirmed screening results as reportedAssessment and Referral: After my interview with the service member and review of this form, there is a need for furtherevaluation and follow-up as indicated below.

10 (More than one may be noted for patients with multiple concerns.)6. Referral Information7. Comments: 8. ProviderDATE (dd/mm/yyyy)DD FORM 2900, JUN 2005 ASD(HA) APPROVED4. Record additional questions or concerns identified by patient during interview:Screening results modified, amended, clarified during interview:5. Identified Concernsh. Substance Abuse Programi. HEALTH Promotion, HEALTH Educationj. Other Healthcare ServiceHealth Care Provider OnlyICD-9 Code for thisvisit: Symptoma. No referral madeExposure ConcernDepression SymptomsPTSD SymptomsAnger/AggressionSuicidal IdeationSocial/Family ConflictAlcohol Use1. Review symptoms and deployment concerns identified on form:MinorConcernMajorConcernAlready Under CareOther:b.