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Table 2-1. Forms and documents of the Health Record (continued). - Outpatient Medical Records Branch - md07510048

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RIGHT SIDE OF FOLDER
Form Number
Form Title and Notes
DA Form 4515
Personnel Reliability Program Record Identifier (see AR 50-5)
*SF 600
Health Record--Chronological Record of Medical Care.
SF 558
Medical Record--Emergency Care and Treatment.
DA Form 5181-R
Screening Note of Acute Medical Care (File here also any
other basic chronological medical care records).
DA Form 3763
Community Health Nursing -- Case Referral.
DA Form 5569- R
Isoniazid (INH) Clinic Flow Sheet.
SF 602
Health Record--Syphilis Record.
DA Form 199
Physical Evaluation Board Proceedings.
DA Form 2173
Statement of Medical Examination and Duty Status.
DA Form 3349
Physical Profile. File here also any correspondence on a
revision of physical profile serials.
DA Form 3947
Medical Evaluation Board Proceedings.
DA Form 4530
Elec troencephalogram Request and History.
DA Form 4700
Medical Record--Supplemental Medial Data (see AR 40-66,
para 7-2b for use and 7-2c for exception to filing).
DA Form 5008
Telephone Medical Advice/Consultation Record. Attach
to a SF 600 (see AR 40-66, para 5-18b(10) for use).
DA Form 5551- R
Spirometry Flow Sheet.
*SF 88
Report of Medical Examination. (Statement in lieu of medical
examination prescribed by NGR 40-501 for ARNG).
*SF 93
Report of Medical History. File here any other medical
history form.
SF 513
Medical Record--Consultation Sheet.
DD Form 2161
Referral for Civilian Medical Care.
*This form must be included in all health records.
Table 2-1. Forms and documents of the Health Record (continued).
MD0751
2-7



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