LEFT SIDE OF FOLDER
Form Title and Notes
DA Form 4186
Medical Recommendation for Flying Duty (see AR 40-501).
DA Form 3180/ 3180A
A Personnel Screening and Evaluation Board (see AR 50-5
and AR 380-380).
Civilian Source Pediatric Growth Charts.
*DA Form 5571
Master Problem List.
DA Form 5510-R
Exceptional Family Member Program Coding Summary
(see AR 600-75.)
Health Record--Immunization Record.
Laboratory Report Display. Filed with SF 546 through
SF 557 mounted.
Radiologic Consultation Request/Report.
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--Electroencephalog ram Request and
DA Form 3647
Inpatient Treatment Record Cover Sheet. File with it a
copy of SF 502 (Medical Record--Narrative Summary), if
prepared. File here also SG Form 84, AF Form 565,
NAVMED 6300/5, or DD Form 1380.
DA Form 5006- R
Authorization for Disclosure of Information.
DA Form 3365
Authorization for Medical Warning Tag (file on left side
when new folders are started).
*This form must be included in all OTRs.
Table 3-1. Forms and documents of the medical OTR (continued).