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STATEMENT OF MEDICAL EXAMINATION AND DUTY STATUS For use of this form, see AR 600-8-4, the proponent agency is DCS, G-1. Through: (Include ZIP Code) TO: (Include ZIP Code) FROM: (Include ZIP Code)

How to fill out statement of medical examination

Who needs a statement of medical examination?

1. Employees: Many employers require their employees to undergo a statement of medical examination as part of their pre-employment process or on a regular basis to ensure their fitness for work and identify any potential health issues that may affect their job performance.
2. Athletes: Athletes participating in competitive sports often need to provide a statement of medical examination to ensure they are in good health and physically fit to participate in their respective sports.
3. Students: Some schools and universities may require students to undergo a statement of medical examination to enroll in certain programs or to participate in specific activities, such as physical education or sports activities.
4. Individuals applying for insurance: Insurance companies may request a statement of medical examination to assess an individual's health status and determine their eligibility for certain types of insurance coverage, such as life or health insurance.

How to fill out a statement of medical examination:

1. Obtain the form: The first step is to obtain the statement of medical examination form, which can typically be obtained from the relevant authority or organization requesting the examination. It may also be available online for download.
2. Personal information: Fill in your personal information, including your full name, date of birth, address, contact details, and any other required identification information.
3. Medical history: Provide a detailed history of any previous medical conditions, surgeries, hospitalizations, allergies, or chronic illnesses you may have had. This information helps the examiner understand your medical background and any potential risks or concerns.
4. Current medications: List all the medications you are currently taking, including over-the-counter medications, vitamins, supplements, and prescribed medications. Specify the dosage and frequency of each medication.
5. Family medical history: Indicate if any immediate family members (parents, siblings) have a history of medical conditions or diseases, as this can provide important insights into potential hereditary or genetic risk factors.
6. Current symptoms or concerns: If you are currently experiencing any symptoms or have specific health concerns, describe them in detail. This information can help the examiner focus on areas of concern during the examination.
7. Signature and date: Sign and date the form to certify that the information provided is accurate to the best of your knowledge.
8. Attending the examination: Once the form is filled out, schedule an appointment with a qualified healthcare professional who can conduct the medical examination. Bring the completed form with you to the appointment, as the examiner will need to review and document the findings accordingly.

Remember, specific instructions may vary depending on the purpose and requirements of the statement of medical examination. It is essential to carefully read the instructions provided with the form and seek clarification if needed.

For pdfFiller’s FAQs

What is statement of medical examination?

Statement of medical examination is a document that provides details about an individual's medical history and current health status.

Who is required to file statement of medical examination?

Individuals applying for certain types of jobs or insurance coverage may be required to file a statement of medical examination.

How to fill out statement of medical examination?

Statement of medical examination can be filled out by providing accurate and complete information about one's medical history, current health status, and any relevant medical conditions.

What is the purpose of statement of medical examination?

The purpose of statement of medical examination is to assess an individual's medical fitness and determine any potential risks or limitations.

What information must be reported on statement of medical examination?

Information such as medical history, current medications, allergies, surgeries, and any ongoing health conditions must be reported on statement of medical examination.

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