Complete the medical and dental status portions below, return the original and one copy to the MDP/PSC within 21 calendar days of the date shown in item 13E, and forward one copy to the address in item 6.
14A. PHYSICAL PROFILE SERIAL CODE |
B. PHYSICAL CATEGORY CODE |
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C. |
MEDICAL RECORDS REVEAL THE FOLLOWING ASSIGNMENT |
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(PULHES) |
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LIMITATIONS |
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YES |
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NO |
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N/A |
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ITEM |
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15A. |
Does the member meet the medical fitness |
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B. IF CONDITION IS TEMPORARY, EXPECTED DATE |
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standards outlined in AR 40-501? (If "no" explain briefly.) |
MEMBER WILL BE ELIGIBLE FOR ASSIGNMENT |
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16A. |
Has member completed HIV screening? |
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B. |
DATE, TIME AND LOCATION OF APPOINTMENT |
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17A. |
Is the member pregnant? |
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B. |
IF "YES", EXPECTED DATE OF DELIVERY |
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18A. |
All active duty and reserve personnel of PCS |
B. IF "YES", INDICATE DATE, TIME, AND LOCATION OF |
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assignment to Korea will be vaccinated with hepatitis |
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APPOINTMENT |
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B vaccine. Does the member require immunization? |
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B. |
IF "YES", INDICATE DATE, TIME, AND LOCATION OF |
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19A. |
Does the member require remedial medical care? |
APPOINTMENT |
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20A. |
Is the member currently undergoing alcohol or |
B. IF "YES", INDICATE DATE THE MEMBER ENTERED |
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drug abuse rehabilitation? |
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THE REHABILITATION PROGRAM |
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21A. |
If item 10 is checked "yes", can the member be |
B. IF "YES", THE MEMBER (and family members, if |
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assigned to an area where medical facilities are limited or |
applicable) MUST BE SCHEDULED FOR A FOLLOW-UP |
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EVALUATION OF MEDICAL STATUS WITHIN 30 CALENDAR |
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nonexistent? |
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DAYS OF THE ANTICIPATED DATE OF LOSS (Item 9). |
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INDICATE DATE, TIME AND LOCATION OF APPOINTMENT(S) |
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22. |
Medical Records Indicate the Member Requires the Following |
(Check those appropriate) |
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REQUIRES |
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HAS |
MISSING |
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ITEM |
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DATE, TIME AND LOCATION OF APPOINTMENT, IF NEEDED |
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A |
Two pairs of spectacles |
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B. |
Protective mask spectacle |
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insert |
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C. |
Two hearing aids |
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D. |
Medical warning tag |
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23A. |
NAME OF MEDICAL OFFICER |
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B. |
TITLE |
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