DD Form 2382 DoD Medical Examination Review Board (DoDMERB) Statement

DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)
STATEMENT OF HISTORY REGARDING ALLERGIES

OMB No. 0704-0396
OMB approval expires
Sep 30, 2006

The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0396). Respondents should be aware that notwithstanding any other provision of
law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO DODMERB/DR, 8034 EDGERTON
DRIVE, SUITE 132, USAF ACADEMY CO 80840-2200.
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 Corps (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 applications 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. NAME OF APPLICANT (Last, First, Middle Initial)

2. SSN OF APPLICANT

INSTRUCTIONS
Please describe any symptoms or problems you have experienced in the following areas. If additional space is needed, use the reverse side
of this form.
3. ALLERGIC RHINITIS (HAYFEVER) OR ANY OTHER ALLERGIES, FREQUENCY/DURATION OF SYMPTOMS

TREATMENT AND/OR MEDICATION. ARE YOU TAKING DESENSITIZATION INJECTIONS?
LIST ANY COMPLICATIONS (Example: sinusitis, ear blocks, etc.)

TREATMENT OR SURGERY FOR THE COMPLICATIONS CONSISTED OF:
4. ASTHMA, REACTIVE AIRWAY DISEASE, OR EXERCISE INDUCED BRONCHOSPASM

AGE OF ONSET

TREATMENT AND/OR MEDICATION

WERE THERE ANY EMERGENCY ROOM VISITS, OR HOSPITALIZATIONS ASSOCIATED WITH YOUR AIRWAY PROBLEM, TO INCLUDE
WHEEZING OR SHORTNESS OF BREATH?
DATE OF LAST ATTACK

FREQUENCY OF MEDICATION USED (Example: daily, weekly, monthly, or just
spring and fall seasons)

DATE OF LAST TREATMENT
OR MEDICATION

5. DESCRIBE ANY PAST OR PRESENT SKIN PROBLEMS SUCH AS ECZEMA, ATOPIC ECZEMA (ATOPIC DERMATITIS), HIVES OR URTICARIA.

6. DESCRIBE CONTACT ALLERGIES (Latex, wool, chemicals, etc.) AND SYMPTOMS.

TREATMENT AND/OR MEDICATION
FREQUENCY OF TREATMENT OR MEDICATION USED (Example: daily, weekly, monthly, or just spring and fall DATE OF LAST TREATMENT
seasons)
OR MEDICATION
7. DESCRIBE ANY ALLERGIC REACTIONS TO FOODS, - SYMPTOMS AND SPECIFIC FOOD.

8. SIGNATURE OF APPLICANT

DD FORM 2382, MAR 2004

9. DATE SIGNED

PREVIOUS EDITION IS OBSOLETE.

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