DD 2796 · Member self-assessment · Page 1
Deployment
Answer all questions based on your most recent deployment. Your responses are reviewed by a health care provider. If a question is unclear, you can discuss it with the provider at your review.
Identity verification (required before your health information is shown — CP §4.3.2)
IDThe record below is prepopulated from your longitudinal record. Confirm this is you before continuing.SourceFactory Data Service · reconciled record & last form · as of 2026-07-01
Required
For your protection, this form will not display health information that may not be yours. Do not continue — contact your PHA administrator to correct your identity record. (Session would end here in the live system.)
Deployment record (prepopulated — confirm)
Questions 1–2 · Health rating
1Overall, how would you rate your health during the past month?
Required
2Compared to before this deployment, how is your health in general now?
Required
Questions 3–9
Your Health During Deployment
Questions 3–9
3How often did you smoke tobacco during your deployment?
Required
4Were you wounded, injured, assaulted, or otherwise hurt during your deployment?
Required
Are you still having problems related to this? If yes, please explain:
5During your deployment, did any of these apply?
Considered in the provider's overall assessment.
6How many times did you visit a health care provider during deployment?
Required
7Did you receive care for combat stress or a mental health concern?
Required
8Did you spend one or more nights in a hospital as a patient?
Required
9In the past month, how difficult have physical health problems made your work or daily activities?
Required
Questions 10–11
Injury & Symptoms
Question 10 · Injury & concussion events
10aDuring this deployment, did any of the following happen to you?
10bAs a result, did you IMMEDIATELY experience any of the following?
Your responses suggest a possible concussion / mild TBI event. The provider will complete a concussion evaluation (blocks 5 & 19–20).
Question 11 · Symptoms in the past month
How much have you been bothered by each of the following? Items a–o form a physical symptom (PHQ-15) score used by your provider.
| Symptom | Not at all | A little | A lot |
|---|---|---|---|
| aStomach pain | |||
| bBack pain | |||
| cPain in arms, legs, or joints | |||
| dMenstrual/period problems (women only) | |||
| eHeadaches | |||
| fChest pain | |||
| gDizziness | |||
| hFainting spells | |||
| iHeart pounding or racing | |||
| jWheezing / shortness of breath | |||
| kPain during sexual intercourse | |||
| lConstipation, loose bowels, or diarrhea | |||
| mNausea, gas, or indigestion | |||
| nFeeling tired / low energy | |||
| oTrouble sleeping | |||
| pTrouble concentrating | |||
| qMemory problems | |||
| rBalance problems | |||
| sNoises in head or ears (ringing, buzzing) | |||
| tTrouble hearing | |||
| uSensitivity to bright light | |||
| vEasily annoyed or irritable | |||
| wFever | |||
| xCough lasting more than 3 weeks | |||
| yNumbness/tingling in hands or feet | |||
| zHard to make decisions | |||
| aaWatery, red eyes | |||
| bbDimming of vision | |||
| ccSkin rash and/or lesion | |||
| ddPain/frequency/urgency with urination | |||
| eeBleeding gums, tooth pain, or broken tooth |
PHQ-15 physical (a–o): 0
"A lot" flags: 0
A physical symptom score of ≥ 15 indicates high generalized post-deployment symptoms — the provider is prompted to consider referral (blocks 6, 19–20).
Questions 12–16
Stress & Mood
These screening questions help your provider understand stress, alcohol use, and mood since your return. Support is available regardless of your answers.
Questions 12–13 · Stressors & medications
12aOver the past month, have you experienced major life stressors causing significant concern?
Required
12b · Are you currently getting professional help for this?
13Are you currently taking any medication (incl. herbals/supplements) for sleep, pain, combat stress, or a mental health concern?
Required
Question 14 · Alcohol (AUDIT-C)
14aHow often do you have a drink containing alcohol?
Required
14bHow many drinks on a typical drinking day?
Required
14cHow often do you have six or more drinks on one occasion?
Required
AUDIT-C: 0
An AUDIT-C score at or above the screening threshold (≥ 4 women / ≥ 5 men) prompts the provider to advise on limits and consider brief counseling or referral.
Question 15 · PTSD screen (PC-PTSD)
In the past month, have you had an experience so frightening, horrible, or upsetting that you…
| In the past month you… | No | Yes |
|---|---|---|
| a. Had nightmares about it or thought about it when you didn't want to | ||
| b. Tried hard not to think about it or avoided reminders | ||
| c. Were constantly on guard, watchful, or easily startled | ||
| d. Felt numb or detached from others, activities, or surroundings |
Positive responses: 0 of 4
Two or more "yes" responses is a positive PTSD screen — the provider will ask follow-up questions and consider referral (block 10).
Question 16 · Mood screen (PHQ-2)
| Over the last 2 weeks, bothered by… | Not at all | Several days | > Half the days | Nearly every day |
|---|---|---|---|---|
| a. Little interest or pleasure in doing things | ||||
| b. Feeling down, depressed, or hopeless |
A response of "more than half the days" or "nearly every day" on either item prompts the provider to assess further (block 11).
If you're struggling right now, you don't have to wait for the review. The 988 Suicide & Crisis Lifeline (call or text 988) and the Veterans/Military Crisis Line (988, then press 1) are available 24/7. Your provider can also connect you with support today.
Questions 17–25
Exposures & Requests
Questions 17–21 · Environmental & exposure concerns
17Are you worried you were exposed to something in the environment while deployed?
Required
18Do you think you were exposed to any chemical, biological, or radiological warfare agents?
Required
19Were you in, or did you inspect, a vehicle hit by a depleted-uranium (DU) round?
Required
20Were you told to take medicines to prevent malaria?
Required
Which did you take, and did you take all pills as directed?
21Were you bitten or scratched by an animal during your deployment?
Required
Questions 22–25 · Requests (optional — check any you'd like)
Provider review (next step — completed with a health care provider)
After you submit, a provider reviews your responses in a face-to-face interview and completes blocks 1–23: concern summary, referrals (24 hr / 7 day / 30 day), and any recommended services. Your screening scores above carry into that review automatically.