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Foot trouble e. Impaired use of arms, legs, hands, or feet b. Lived with someone who had tuberculosis c. Coughed up blood h. Swollen or painful joint s d.
Asthma or any breathing problems related to exercise, weather, i. Knee trouble e. Any knee or foot surgery including arthroscopy or the use of a scope e. Shortness of breath to any bone or joint k.
Any need to use corrective devices such as prosthetic devices, knee f. Bronchitis brace s , back support s , lifts or orthotics, etc.
Bone, joint, or other deformity g. Wheezing or problems with wheezing m. Plate s , screw s , rod s or pin s in any bone h. Been prescribed or used an inhaler n. Broken bone s cracked or fractured i. A chronic cough or cough at night j. Sinusitis Frequent indigestion or heartburn k. Hay fever b. Stomach, liver, intestinal trouble, or ulcer c. Gall bladder trouble or gallstones l.
Chronic or frequent colds Severe tooth or gum trouble d. Jaundice or hepatitis liver disease b. Thyroid trouble or goiter e. Eye disorder or trouble f. Rectal disease, hemorrhoids or blood from the rectum d. Ear, nose, or throat trouble g. Skin diseases e. Loss of vision in either eye h.
Frequent or painful urination f. Worn contact lenses or glasses i. High or low blood sugar g. A hearing loss or wear a hearing aid j.
Kidney stone or blood in urine h. Sugar or protein in urine l. Sexually transmitted disease syphilis, gonorrhea, chlamydia, genital Painful shoulder, elbow or wrist e. Arthritis, rheumatism, or bursitis Adverse reaction to serum, food, insect stings or medicine c. Recurrent back pain or any back problem b. Recent unexplained gain or loss of weight c.
Currently in good health If no, explain in Item 29 on Page 2. Numbness or tingling e. Loss of finger or toe d. Every item marked "YES" must be fully explained in Item 29 below. Dizziness or fainting spells Have you been refused employment or been unable to hold a job or stay in school because of: b. Frequent or severe headache a. Sensitivity to chemicals, dust, sunlight, etc. A head injury, memory loss or amnesia b.
Inability to perform certain motions d. Paralysis c. Inability to stand, sit, kneel, lie down, etc. Seizures, convulsions, epilepsy or fits d. Other medical reasons If yes, give reasons.
Car, train, sea, or air sickness g. A period of unconsciousness or concussion Have you ever been treated in an Emergency Room? If yes, for what? Meningitis, encephalitis, or other neurological problems Rheumatic fever Have you ever been a patient in any type of hospital? If yes, specify when, where, why, and name of doctor and complete b. Prolonged bleeding as after an injury or tooth extraction, etc. Pain or pressure in the chest d.
Palpitation, pounding heart or abnormal heartbeat Have you ever had, or have you been advised to have any e. Heart trouble or murmur operations or surgery? If yes, describe and give age at which occurred. High or low blood pressure Nervous trouble of any sort anxiety or panic attacks Have you ever had any illness or injury other than those already noted?
If yes, specify when, where, and give details. Habitual stammering or stuttering c. Loss of memory or amnesia, or neurological symptoms Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the past 5 years for d.
Frequent trouble sleeping other than minor illnesses? If yes, give complete address of doctor, hospital, clinic, and details. Received counseling of any type f. Depression or excessive worry Have you ever been rejected for military service for any g.
Been evaluated or treated for a mental condition reason? If yes, give date and reason for rejection. Attempted suicide i. Used illegal drugs or abused prescription drugs Have you ever been discharged from military service for any reason?
If yes, give date, reason, and type of discharge; Have you ever had or do you now have: whether honorable, other than honorable, for unfitness or unsuitability. Treatment for a gynecological female disorder b. A change of menstrual pattern Have you ever received, is there pending, or have you ever applied for pension or compensation for any disability c.
Any abnormal PAP smears or injury? If yes, specify what kind, granted by whom, and what amount, when, why. Have you ever been denied life insurance?
DD Form 2807-1 "Report of Medical History"