Pre-Deployment Health Assessment

This statement serves to inform you of the purpose for collecting the personal information required by the DD Form 2795, Pre-Deployment Health Assessment, and how it will be used. AUTHORITY: 10 U.S.C. 136; 10 U.S.C. 1074f; DoDD 1404.10; DoDD 6490.02E; and E.O. 9397 (SSN), as amended. PURPOSE: To collect information on your physical and mental health status prior to a deployment in a combat, contingency, or other operation outside of the United States, and to assist health care providers in administering present or future care. DISCLOSURE: Voluntary. However, if you choose not to provide the requested information comprehensive health care services may not be possible or administrative delays may occur. Care will not be denied.

INSTRUCTIONS: You are encouraged to answer all questions. You must at least complete the first portion on who you are and when you will deploy. If you do not understand a question, please discuss the question with a health care provider.

Identification and deployment information. Fields shown blank (demonstration — notional data).

To be completed by the deploying Service member.

During the PAST MONTH, how much have you been bothered by any of the following problems?

Have you ever had any experience that was so frightening, horrible, or upsetting that, in the PAST MONTH, you:

NOTE: If 2 or more items on 11a. through 11d. are marked yes, continue to answer items 11e. through 11v. For each, indicate how much you have been bothered by that problem in the PAST MONTH (Not at all / A little bit / Moderately / Quite a bit / Extremely).

Over the LAST 2 WEEKS, how often have you been bothered by the following problems?

NOTE: If 12a. or 12b. are marked "More than half the days" or "Nearly every day," continue to answer items 12c. through 12i.

This section is completed by the health care provider. Deployer is deploying to ____; has deployed ____ times before; last returned ____.

1. Address concerns identified on deployer questions 1 through 8. For each, indicate whether the item was not answered or the deployer indicated a concern/yes, and add provider comments if indicated.

3. Alcohol use as reported in deployer question 10. Use the AUDIT-C score with the Alcohol Use Intervention Matrix (score of 5-7 men / 4-7 women, or ≥ 8) to determine advice, brief counseling, and referral.

4. PTSD screening as reported in deployer question 11. Use the PCL-C score and level of functioning with the Post-Traumatic Stress Disorder Intervention Matrix.

5. Depression screening as reported in deployer question 12. Use the PHQ-8 score and level of functioning with the Depression Intervention Matrix.

9. Medical History Review — if available, hard copy and/or electronic health records (including DD2766 and SF-600 entries, and most recent past deployment health assessments).

Assessment and Referral: After review of deployer's responses and interview with the deployer, the assessment and need for further evaluation is indicated in blocks 11 through 14.

11. Summary of provider's identified concerns needing referral (mark all that apply — Yes / No):

12. Recommended referral(s) (mark all that apply even if deployer does not desire — Within 24 hours / Within 7 days / Within 30 days):