Member Forms / DD FORM 2796

DD FORM 2796

Post-Deployment Health Assessment

On return from deployment

Post-deployment

Demographics

You are encouraged to answer all questions. You must at least complete the first portion on who you are and when and where you deployed. If you do not understand a question, please discuss the question with a health care provider. (Demonstration — notional data only; fields are blank.)

Last Name

First Name

Middle Initial

Social Security Number

Today's Date (dd/mmm/yyyy)

Date of Birth (dd/mmm/yyyy)

Sex

Male Female

Service Branch

Air Force Army Navy Marine Corps Coast Guard Civilian Expeditionary Workforce (CEW) USPHS Other Defense Agency

Other Defense Agency — List

Component

Active Duty National Guard Reserves Civilian Government Employee

Pay Grade

E1 E2 E3 E4 E5 E6 E7 E8 E9 O1 O2 O3 O4 O5 O6 O7 O8 O9 O10 W1 W2 W3 W4 W5 Other

Home station/unit

Current contact information

Phone

Cell

DSN

Address

Point of contact who can always reach you

Name

Phone

Address

Most Recent Deployment

Please answer all questions based on your most recent deployment.

Date arrived theater (dd/mmm/yyyy)

Date departed theater (dd/mmm/yyyy)

Location of operation — To what areas were you mainly deployed? (Please list all that apply, including the number of months spent at each location.)

Country 1

Time at location (months)

Country 2

Time at location (months)

Country 3

Time at location (months)

Country 4

Time at location (months)

Country 5

Time at location (months)

General Health (Questions 1–10)

Member self-report.

1. Overall, how would you rate your health during the PAST MONTH?

Excellent Very Good Good Fair Poor

2. Compared to before this deployment, how would you rate your health in general now?

Much better now than before I deployed Somewhat better now than before I deployed About the same as before I deployed Somewhat worse now than before I deployed Much worse now than before I deployed

If somewhat/much worse, please explain

3. How often did you smoke tobacco (for example cigarettes, cigars, pipe, or hookah) during your deployment?

Just about every day Some days Not at all

4. Were you wounded, injured, assaulted or otherwise hurt during your deployment?

If yes, are you still having any problems or concerns related to this event?

If yes, please explain

5.a. During your deployment, did you ever feel like you were in great danger of being killed?

5.b. Did you encounter dead bodies or see people killed or wounded during this deployment?

5.c. Did you engage in direct combat where you discharged a weapon?

6. How many times during your deployment did you visit a health care provider for a medical or dental health problem/concern?

No visits 1 visit 2-3 visits 4-5 visits 6 or more

7. During this deployment did you receive care for combat stress or a mental health problem/concern?

If yes, please explain

8. During this deployment, did you have to spend one or more nights in a hospital as a patient?

Reason/dates

9. During the PAST MONTH, how difficult have physical health problems (illness or injury) made it for you to do your work or other regular daily activities?

Not difficult at all Somewhat difficult Very difficult Extremely difficult

Question 10 — Deployment Injury & Concussion

10.a. During this deployment, did any of the following events happen to you? (Mark all that apply)

(1) Blast or explosion (e.g., IED, RPG, EFP, land mine, grenade, etc.)?

If yes, please estimate your distance from the closest blast or explosion:

Less than 25 meters (82 feet) 25-50 meters (82-164 feet) 50-100 meters (164-328 feet) More than 100 meters (328 feet)

(2) Vehicular accident/crash (any vehicle including aircraft)?

(3) Fragment wound or bullet wound? — a. Head or neck

(3) Fragment wound or bullet wound? — b. Rest of body

(4) Other injury (e.g., sports injury, accidental fall, etc.)?

If yes to any of the above, please explain

10.b. As a result of any of the events in 10.a., did you receive a jolt or blow to your head that IMMEDIATELY resulted in:

(1) Losing consciousness (“knocked out”)?

If yes, for about how long were you knocked out?

Less than 5 min 5-30 min more than 30 min

(2) Losing memory of events before or after the injury?

(3) Seeing stars, becoming disoriented, functioning differently, or nearly blacking out?

10.c. How many total times during this deployment did you receive a blow or jolt to your head? (only answer if you had a yes to any of the questions on 10a.)

0 1 2 3 more than 3

If more than 3, list number of times