Report of Medical Assessment

Separation / retirement / transition

As directed

Component & duty status

Confirm your component. Reserve and Guard members complete the additional items — availability, Line of Duty, and TRICARE Reserve Select drive eligibility and periodicity.

Component

Current duty status

Line of Duty (LOD) status

TRICARE Reserve Select

RC unit / state

Mobilization date (if applicable)

⚠ Reserve Component member — PHA/readiness periodicity follows the drill cycle; complete the Line of Duty and TRICARE Reserve Select items.

Transition

Completed at separation, retirement, or as directed.

Reason for assessment

Effective date

Do you intend to seek VA disability?

Have you been treated since your last exam?

Health since last examination

Any new illnesses, injuries, or conditions?

Describe conditions / ongoing care

Currently taking medications?

Attest

Member attestation: this report is complete and accurate as of the effective date.