Department of Medicine
Acute Care
Templates
Organizational Charts
Telephone Features
Practice Guidelines
Screening
Hormone Replacement Therapy
Department Forms
Government Forms
3750-17.pdf MIR01
3750-18.pdf MIR02
3750-19.pdf MIR03
5100-14.pdf Workplace Monitoring Plan
5100-15.pdf Medical Surveillance Questionnaire
5100-17.pdf Heat Stress Monitoring Sheet
5102-7.pdf Log of Navy Injuries and Occupational
Illnesses
5102-9.pdf OpNav Safety Report
5200-5A.pdf Planning Calendar
5527-19.pdf Desk Journal
A1045.pdf Army Ideas for Excellence
a1260_r.pdf Telecon Item Record
a1559_r.pdf Inspector General Action Request
A1900.pdf Conversion Mean to Sidereal
A1901.pdf Conversion Sidereal to Mean
a1971_5r.pdf Unit
Radiation Dose Record
A2173.pdf Statement of Medical Examination and
Duty Status
a2789_2r.pdf Medical
Summary Report
A2823.pdf Sworn Statement
a3081_r.pdf Periodic Medical Examination Exemption
a3083_r.pdf Medical Exam for Certain Geographical Areas
a3085_r.pdf Expert Field Medical Badge Qualification
A3349.pdf Physical Profile
A3365.pdf Authorization for Medical Warning Tag
A3437.pdf Certificate of Medical Examination
Nonappropriated
A3586.pdf Report of Professional Officer of the
Day
A3647.pdf Inpatient Cover Sheet
A3666.pdf Statement of Physical Ability for Light
Duty
a3711_r.pdf Alcohol and Drug ADAPCP Resource and
Performance
A3761.pdf Community Health Nursing Activities
A3762.pdf Community Health Nursing Family Record
A3763.pdf Community Health Nursing Case Referral
A3821.pdf Report of Administrative Officer of the
Day
A3888.pdf Nursing Assessment
a3888_2.pdf Medical Record Nursing Care Plan
a3888_3.pdf Medical Record Nursing Discharge Summary
a3889_1.pdf Nursing 24 hour Report
a3897_r.pdf Tuberculosis Registry
A3947.pdf Medical Evaluation Board Proceedings
A3949.pdf Controlled Substances Record
A3950.pdf Flowsheet for Vital Signs and Other
Parameters
A3981.pdf Transfer of Patient
A3982.pdf Medical and Dental Appointment
A3984.pdf Dental Treatment Plan
A4029.pdf Patients Clearance Record
a4036_r.pdf Medical and Dental Preparation for
Overseas Movement
A4186.pdf Medical Recommendation for Flying Duty
A4221.pdf Diabetic Record
a4254_r.pdf Request for Private Medical Information
a4352_1r.pdf Request Medicolegal Examination
a4352_r.pdf Request Medicolegal Examination
a4359_r.pdf Authorization Psychiatric Treatment
a4460_r.pdf Army Law Library Shelf List
a4466_r.pdf Patient Progress Report
A4677.pdf Therapeutic Documentation Care Plan
A4678.pdf Therapeutic Documentation Care Plan
Medications
a4691_r.pdf Initial Application for Clinical
Privileges
A4700.pdf Supplemental Medical Data
a4711_r.pdf Statement of Law Violations
A4753.pdf Notice of Unsafe or Unhealthful Working
Condition
A4755.pdf Employee Report of Alleged Unsafe or
Unhealthful
a4787_1.pdf Request Evaluation Dependent
Medical/Educational
a4843_r.pdf Guest Attendance Sheet
a4881_4r.pdf Power of Attorney
a5006_r.pdf Authorization for Disclosure of
Information
a5007a_r.pdf Allergy Immunotherapy Record
A5008.pdf Telephone Medical Advice Consultation
Record
A5072.pdf Emergency Action Statement
a5142_r.pdf Inspector General Action Request System
A5179.pdf Preop/Postop Nursing Document
a5181_r.pdf Screening Note of Acute Medical Care
A5184.pdf Consumer Complaint
a5187_r.pdf Application for Respite Caregivers
a5188_r.pdf Med Report Cert Disability Care
a5189_r.pdf Application for Respite Care
a5190_r.pdf Clinician’s Information
a5191_r.pdf Information on Individual with
Disability
a5195_r.pdf Health Data Immunizations
a5275_r.pdf Time Study Record
a5276_r.pdf Program Management Data
a5277_r.pdf Operational Audit Data
a5278_ra.pdf Work Sampling Record
a5278_rb.pdf Work Sampling Computations
a5441_3a.pdf Evaluation of Privileges Internal Medicine
and Subsp
a5551_r.pdf Spirometry Flow Sheet
a5569_r.pdf INH Flowsheet
A5571.pdf Master Problem List
a5611_r.pdf Document Summary
a5624_r.pdf Defibrillator Inspection Record
a5841_r.pdf Special Instructions Power of Attorney
a5862_r.pdf Army Exceptional Family Member Summary
A6.pdf Duty Roster
a705_a.pdf Army Physical Fitness Test Scorecard
a705_b.pdf Army Physical Fitness Test Scorecard
a705_c.pdf Army Physical Fitness Standards Situp
a705_d.pdf Army Physical Fitness Standards
Pushup
A7095.pdf ADAPCP Outpatient Discharge Summary
A7096.pdf ADAPCP Outpatient Plan
A7097.pdf ADAPCP Outpatient Problem List
A7098.pdf ADAPCP Outpatient Treatment Plan
a7099_a.pdf Social Support
a7099_b.pdf Thought Processes
a7279_1r.pdf EEO Resolution Assessment
a7279_r.pdf EEO Complaint Form
A7389.pdf Medical Record Anesthesia
ChargeDD0458.pdf Charge Sheet
CorrectionDD0149.pdf Application Correction Military Record
D1351.pdf Travel Voucher
d1351_2.pdf Travel Voucher or Subvoucher
d1351_2c.pdf Travel Voucher or Subvoucher
D1572b.p df Test Results
D2161.pdf Civilian Referral
D2341.pdf Report of Animal Bite
D2343.pdf Veterinary Health Record
D689.pdf Individual Sick Slip
D771.pdf Eyewear RX
D792.pdf 24 hour I and O
DD0093.pdf Record of Emergency Data
DD0689.pdf Individual Sick Slip
DD0739.pdf Register of Patients
DD0771.pdf Eyewear RX
DD0877.pdf Request for Med/Dental Records or
Info
DD0877-1.pdf Request for Med/Dental Records from
National
DD0890.pdf Record of Identification Processing
DD0891.pdf Record of Identification Processing
Dental Chart
DD0893.pdf Record of Identification Processing
Anatomical
DD0894.pdf Record of Identification Processing
Fingerprint
DD1569.pdf Incident Complaint Form
DD1723.pdf Flow Process Chart
DD2005.pdf Privacy Act Health Care
Records
DD2030.pdf Activity Task List
DD2138.pdf Request for Transfer of Outpatient
Record
DD2161.pdf Referral for Civilian Care
DD2215.pdf Reference Audiogram
DD2216.pdf Hearing Conservation
DD2341.pdf Report of Animal Bite
DD2343.pdf Veterinary Health Record
DD2369.pdf MERB Cycloplegic Refraction
DD2370.pdf MERB 3Day BP and Pulse
DD2372.pdf MERB Statement of Present Health
DD2374.pdf MERB Heart Murmur
DD2378.pdf MERB Headaches
DD2379.pdf MERB Head Injury
DD2380.pdf MERB Sleepwalking
DD2381.pdf MERB Motion Sickness
DD2382.pdf MERB Allergies
DD2480.pdf MERB Dental
DD2489.pdf MERB Red/Green
DD2492.pdf MERB History
DD2493-1.pdf Asbestos Exposure
DD2493-2.pdf Asbestos Periodic Medical
DD2499.pdf Health Care Practitioner Action
Report
DD2526.pdf Case Abstract Malpractice
DD2527.pdf CHAMPUS Liability
DD2632.pdf MERB Body Fat
DD2697.pdf Report of Medical Assessment
DD2770.pdf Abbreviated Medical Record
DD2792.pdf Instructions Exceptional Family
Member
DD2795.pdf Pre-Deployment Health Assessment
DD2796.pdf Post-Deployment Health Assessment
DD2797S.pdf TSP Enrollment
DD2807-1.pdf Report of Medical History
DD2807-2.pdf Instructions for Medical History
DD2808.pdf Report of Medical Examination
DD2813.pdf Reserve Dental
S504.pdf Medical Record History 1
S505.pdf Medical Record History 2
S506.pdf Medical Record Physical
S507.pdf Continuation
S516.pdf Operation Report
S527a.pdf Group Muscle Strength
S527b.pdf Group Muscle Strength (continued)
S530.pdf Neurological Exam
S535.pdf Newborn
S536.pdf Pediatric Nursing
S538.pdf Pediatric Family History
S539.pdf Abbreviated Medical Record
S558.pdf Emergency Care and Treatment
Doctor
S600.pdf 600
S601.pdf Immunization Record
State of Washington Forms