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    Orthopedic Injury Questionnaire

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    1) The document is an orthopedic questionnaire from the DoD Medical Examination Review Board requesting information about any orthopedic conditions or injuries from an applicant. 2) It asks the applicant to list and number any orthopedic conditions/injuries, and then answer a series of questions for each condition/injury regarding when it occurred, how it was treated, if treatment is ongoing, any residual pain or discomfort, need for external supports, and extent of participation in athletic/recreational activities over the last 12 months or since the condition/injury. 3) The applicant must certify that the information provided is true and accurate.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Orthopedic Injury Questionnaire

    Uploaded by

    dc
    269 views1 page
    1) The document is an orthopedic questionnaire from the DoD Medical Examination Review Board requesting information about any orthopedic conditions or injuries from an applicant. 2) It asks the applicant to list and number any orthopedic conditions/injuries, and then answer a series of questions for each condition/injury regarding when it occurred, how it was treated, if treatment is ongoing, any residual pain or discomfort, need for external supports, and extent of participation in athletic/recreational activities over the last 12 months or since the condition/injury. 3) The applicant must certify that the information provided is true and accurate.

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    form for getting waivers in the army

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    1) The document is an orthopedic questionnaire from the DoD Medical Examination Review Board requesting information about any orthopedic conditions or injuries from an applicant. 2) It asks the applicant to list and number any orthopedic conditions/injuries, and then answer a series of questions for each condition/injury regarding when it occurred, how it was treated, if treatment is ongoing, any residual pain or discomfort, need for external supports, and extent of participation in athletic/recreational activities over the last 12 months or since the condition/injury. 3) The applicant must certify that the information provided is true and accurate.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    269 views1 page

    Orthopedic Injury Questionnaire

    Uploaded by

    dc
    1) The document is an orthopedic questionnaire from the DoD Medical Examination Review Board requesting information about any orthopedic conditions or injuries from an applicant. 2) It asks the applicant to list and number any orthopedic conditions/injuries, and then answer a series of questions for each condition/injury regarding when it occurred, how it was treated, if treatment is ongoing, any residual pain or discomfort, need for external supports, and extent of participation in athletic/recreational activities over the last 12 months or since the condition/injury. 3) The applicant must certify that the information provided is true and accurate.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    DoD Medical Examination Review Board

    8034 Edgerton Drive, Suite 132


    USAF Academy, Colorado 80840-2200

    ORTHOPEDIC QUESTIONNAIRE
    NAME: _____________________________________SOCIAL SECURITY NUMBER: _________-_______-_________
    Please complete the questions below regarding history of injury(ies) and/or orthopedic conditions and return this form to
    DoDMERB at the address above: If more space is needed, please use back of form and identify each issue by question number.
    ____________________________________________________________________________________________________________
    PRIVACY ACT STATEMENT
    AUTHORITY: Title 10, USC 133, 3012, 5031, 8013, and Executive Order 9397
    PRINCIPAL PURPOSE: To determine medical acceptability or update a medical file as part of the application process to a United States Service Academy, Reserve
    Officer Training Corp (ROTC) Scholarship Program, or the Uniformed Services University of the Health Sciences (USUHS).
    ROUTINE USES: This information may be disclosed to the Coast Guard Academy and Merchant Marine Academy for applicants to their Academies.
    DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection process and hamper your candidacy. Use of the Social
    Security Number (SSN) is used for positive identification of records.

    ____________________________________________________________________________________________________________

    1) Please list EVERY orthopedic condition and/or injury (PLEASE NUMBER each condition/injury and retain number
    sequence in questions below):__________________________________________________________________________
    __________________________________________________________________________________________________
    PLEASE ENSURE YOU ANSWER THE FOLLOWING QUESTIONS FOR EACH CONDITION AND/OR INJURY LISTED ABOVE:

    2) When did the orthopedic condition(s)/injury(ies) occur? __________________________________________________


    __________________________________________________________________________________________________
    __________________________________________________________________________________________________
    3) How was/were the orthopedic condition(s) treated? _____________________________________________________
    __________________________________________________________________________________________________
    __________________________________________________________________________________________________
    4) Is treatment still ongoing (answer YES or NO for each condition/injury)?_____________________________________
    __________________________________________________________________________________________________
    __________________________________________________________________________________________________
    5) Do you have any residual pain and/or discomfort with any of your orthopedic condition(s)/injury(ies)? YES
    NO
    If yes, please explain: ______________________________________________________________________________
    __________________________________________________________________________________________________
    6) Do you now require any external supports, (e.g., knee braces, lifts, ankle taping, orthotics, etc)?
    YES
    NO
    If yes, please explain for each condition/injury:__________________________________________________________
    __________________________________________________________________________________________________
    7) Please describe the extent of your participation in athletic activities and/or recreational activities during the last 12
    months. If your condition/injury occurred less than 12 months ago, please explain the extent of your participation in
    athletic activities and/or recreational activities since your condition/injury?____________________________________
    ____________________________________________________________________________________________________________
    ____________________________________________________________________________________________________________

    8) Certification: By signing below, I hereby certify that the above information is true and accurate to the best of my
    knowledge.

    _________________________________________
    Applicants Signature

    _____________________
    Date

    Orthopedic Questionnaire

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