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Form Number
Form Title and Notes
DA Form 4515
Personnel Reliability Program Record Identifier
(see AR 50-5).
*SF 600/SF 558
Health Record--Chronological Record of Medical
Care. File here also any other basic chronological
medical care records (e.g., SF 558, Medical Record--
Emergency Care and Treatment; and AMOSIST
Encounter Forms).
State Ambulance Forms.
DA Form 5568- R
Chronological Record of Well-Baby Care.
DA Form 3763
Community Health Nursing--Case Referral.
DA Form 5569-R
Isoniazid (INH) Clinic Flow Sheet.
DA Form 4700
Medical Record--Supplemental Medical Data.
DA Form 5008
Telephone Medical Advice/Consultation Record.
Attach to a SF 600.
SF 513/DD Form 2161 Medical Record--Consultation Sheet/Referral for
Civilian Medical Care.
SF 522
Medical Record--Request for Administration of
Anesthesia and for Performance of Operations
and Other Procedures.
SF 559
Medical Record--Allergen Extract Prescription--New
and Refill.
DD Form 2482
Venom Extract Prescription.
DA Form 5007- R
Record of Hyposensitization.
Other SF 500 series forms in numerical sequence.
*This form must be included in all OTRs.
Table 3-1. Forms and documents of the medical OTR (continued).
MD0751
3-4
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