LEFT SIDE OF FOLDER
Form Title and Notes
DA Form 4186
Medical Recommendation for Flying Duty
(see AR 40 - 501).
DA Form 3180/3180A
Personnel Screening and Evaluation Board
(see AR 50-5).
*DA Form 5571
Master Problem List.
DA Form 2482
Venom Extract Prescription.
Health Record--Immunization Record.
DA Form 4970
Medical Screening Summary. Over-40 Physical Fitness
Program (see AR 40-501).
DD Form 1141
Record of Occupational Exposure to Ionizing Radiation
(see AR 40-14).
Laboratory Report Display. Filed with SFs 546 through
Clinical Record--Electrocardiograph Record. Reports of
electrocardiograph examinations with adequate
representative tracings should be attached to the back of
this form or on another attached sheet of paper.
Medical Record--Electroencephalogram Request and
DA Form 3647
Inpatient Treatment Record Cover Sheet. Medical Record
& SF 502
--Narrative Summary. Copies of these forms will be filed in the
HREC to indicate a previous admission. File SG Form 84, AF
Form 565,NAVMED 6300/5, DD Form 1380, or any other
narrative summaries from the Veterans Administration, Public
Health Service, or other Government MTF here also.
DA Form 5006- R
Authorization For Disclosure of Information.
DA Form 3365
Authorization for medical Warning Tag.
* This form must be included in all health records.
Table 2-1. Forms and documents of the Health Record (continued).