Forms are communication templates. They may involve requests, responses, documentation of findings, or provide standardized calculations or algorithms of care.
In many military settings, electronic medical record systems have largely or entirely replaced paper forms. But in some military settings, EMRs may not be available or functional. In such cases, having access to standard forms can prove useful in providing care.
Over 90 medical forms are provided here, in two general categories…OBGYN specific, and General Medical and Administration. All have been used at one time or another in support of military medical populations.
In some cases, the listed forms have been updated. In other cases, they have been withdrawn as obsolete. An official source for the most current DoD forms is the DoD Forms Management Program.
OBGYN Specific Forms
| Gynecology Forms | Current History Review |
| Gynecology Forms | Office Exam |
| Gynecology Forms | Menstrual Flow Record |
| Ultrasound Forms | Ultrasound Measurements in Pregnancy |
| Obstetric Forms | Cervical Dilatation Chart |
| Obstetric Forms | Gestational Age Calculator |
| Obstetric Forms | OB History |
| Obstetric Forms | OB Flow Sheet |
| Obstetric Forms | Prenatal Information |
General Medical and Administration Forms
| Standard Form 88 | Report of Medical Examination |
| Standard Form 93 | Medical Record – Report of Medical History |
| Standard Form 504 | Medical Record History – Part I |
| Standard Form 505 | Medical Record History – Part II |
| Standard Form 506 | Clinical Record – Physical Examination |
| Standard Form 507 | Clinical Record – Continuation Sheet |
| Standard Form 509 | Medical Record – Progress Notes |
| Standard Form 513 | Medical Record – Consultation Request/Report |
| Standard Form 515 | Medical Record – Tissue Examination Request/Report |
| Standard Form 516 | Medical Record – Operation Report |
| Standard Form 522 | Request for Anesthesia and Operations |
| Standard Form 531 | Anatomical Figure |
| Standard Form 533 | Medical Record – Prenatal and Pregnancy |
| Standard Form 535 | Clinical Record – Newborn |
| Standard Form 536 | Pediatric Nursing Notes |
| Standard Form 538 | Clinical Record – Pediatric History |
| Standard Form 539 | Abbreviated Medical Record |
| Standard Form 541 | Medical Record – Gynecologic Cytology |
| Standard Form 558 | Medical Record – Emergency Care and Treatment |
| Standard Form 600 | Medical Record – Chronologic Record of Medical Care |
| Standard Form 601 | Health Record – Immunization Record |
| DA Form 3349 | Physical Profile |
| DA Form 3349 (Modified) | Physical Profile for the Post-Partum Soldier |
| DA Form 5304-R | Family Care Plan Counseling Checklist |
| DA Form 5305-R | Family Care Plan |
| NAVMED Form 6150/2 | Special Duty Medical Abstract |
| NAVMED Form 6410/1 | Grounding Notice (Aeromedical) |
| NAVMED Form 6410/2 | Clearance Notice (Aeromedical) |
| GYN Exam Template | Overprint for SF600 |
| DD Form 7 | Report of Treatment Furnished Pay Patients (Hospitalized) |
| DD Form 7A | Report of Treatment Furnished Pay Patients (Outpatient) |
| DD Form 675 | Receipt for Records and Patient’s Property |
| DD Form 689 | Individual Sick Slip |
| DD Form 739 | Register of Patients (Numeric) |
| DD Form 771 | Eyewear Prescription |
| DD Form 1351 | Travel Voucher |
| DD Form 1351-2 | Travel Voucher or Subvoucher |
| DD Form 1351-2C | Travel Voucher or Subvoucher Continuation Sheet |
| DD Form 1351-3 | Statement of Actual Expenses |
| DD Form 1351-5 | Government Quarters and/or Mess |
| DD Form 1569 | Incident/Complaint Report |
| DD Form 1920 | Alcoholic Influence Report |
| DD Form 1924 | Surgical Checklist |
| DD Form 2005 | Privacy Act Statement – Healthcare Records |
| DD Form 2138 | Request for Transfer of Outpatient Record |
| DD Form 2161 | Referral for Civilian Care |
| DD Form 2322 | Dental Laboratory Work Authorization |
| DD Form 2341 | Report of Animal Bite – Potential Rabies Exposure |
| DD Form 2351 | DOD Medical Examination Review Board – Report of Medical Examination |
| DD Form 2369 | DOD Medical Examination Review Board – Cycloplegic Refraction |
| DD Form 2370 | DOD Medical Examination Review Board – 3 Day BP and Pulse Check |
| DD Form 2372 | DOD Medical Examination Review Board – Statement of Present Health |
| DD Form 2374 | DOD Medical Examination Review Board – Heart Murmur Evaluation |
| DD Form 2378 | DOD Medical Examination Review Board – Statement of History re: Headaches |
| DD Form 2379 | DOD Medical Examination Review Board – Statement of History re: Head Injury |
| DD Form 2380 | DOD Medical Examination Review Board – Statement of History re: Sleepwalking |
| DD Form 2381 | DOD Medical Examination Review Board – Statement of History re: Motion Sickness |
| DD Form 2382 | DOD Medical Examination Review Board – Statement of History re: Allergies |
| DD Form 2480 | DOD Medical Examination Review Board – Report of Dental Examination |
| DD Form 2489 | DOD Medical Examination Review Board – Farnsworth Lantern and Red/Green Color Vision Tests |
| DD Form 2492 | DOD Medical Examination Review Board – Report of Medical History |
| DD Form 2493-1 | Asbestos Exposure – Part (1) Initial Medical Questionnaire |
| DD Form 2493-2 | Asbestos Exposure – Part (2) Periodic Medical Questionnaire |
| DD Form 2499 | Health Care Practitioner Action Report |
| DD Form 2544 | Diving Log |
| DD Form 2551 | Workload Management System for Nursing – General Worksheet |
| DD Form 2552 | Workload Management System for Nursing – Psychiatric Worksheet |
| DD Form 2576 | DOD Bone Marrow and Donor Program – Donor Information and Health Screening |
| DD Form 2620 | Request for and Report of Laboratory Examination for Rabies |
| DD Form 2632 | DOD Medical Examination Review Board – Body Fat Determination |
| DD Form 2697 | Report of Medical Assessment |
| DD Form 2731 | Organ and Tissue Donor Card |
| DD Form 2766 | Adult Preventive and Chronic Care Flowsheet |
| DD Form 2770 | Abbreviated Medical Record |
| DD Form 2792 | Exceptional Family Member Medical and Educational Summary |
| DD Form 2795 | Pre-deployment Health Assessment |
| DD Form 2796 | Post-deployment Health Assessment |
