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MEDICAL RECORD REPORT OF MEDICAL HISTORY NO. OF ATTACHED SHEETS DATE OF EXAM NOTE This information is for official and medically-confidential use only and will not be released to unauthorized persons 1. WEIGHT 9. ARE YOU Check one 8. PATIENT S OCCUPATION RIGHT HANDED LEFT HANDED 10. PAST/CURRENT MEDICAL HISTORY CHECK EACH ITEM YES NO DON T KNOW Household contact with anyone with tuberculosis Shortness of breath Chronic cough Blood in sputum or when coughing Palpitation or pounding heart...
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Laws dot-com legal forms guide a DD Form 93 is a Department of Defense form used to gather information to be used for notification in case of an emergency or death it is used by both military members and contractors mainly those in high-risk areas the DD Form 93 is available on the Department of Defense documentation website or can be supplied through the chain of command in order to properly fill out a DD Form 93 you must start by gathering your emergency contact information record your personal information in boxes 1 through 3 providing your name social security number and your military division or civilian category in box 4 provide your spouse's name and address if you do not have a spouse you should leave this box blank however you can include a former spouse in this box in box 5 you must list all of your children the relationship to you their dates of birth and their contact information including address and phone number boxes 6 and 7 are to be used for identifying your parents with each parents address if you do not want any of the above to be notified in case of injury or ill health state in box 8 who not to notify and who to notify in their place for military personnel they must name a designated military person and their address in box 9 for box 10 contractors must put their contracting company and the contact information at this point non-military members have completed the form and need to only certify the DD Form 93 on the second page with their signature and date military members are required to name beneficiaries of death benefits in boxes 11 12 and 13 these beneficiaries cover death gratuity unpaid pay and benefits each beneficiary must be listed with a percentage of benefits they will receive list each beneficiary's name and contact information once completed the form must be certified and filed with the Department of Defense keep a copy for your records to watch more videos please make sure to visit laws com