DA FORM 2173, STATEMENT OF MEDICAL EXAMINATION AND DUTY
Procedures to complete DA Form 2173.
Patient's present unit and zip code
Address of patient's next higher command
Address of patient's medical treatment facility
The following information will be taken from DA Form 2895, Admissions and
Name of patient examined
Patient's organization and station
Example: 20 Jan 8X
Place of accident
Example: Ft. Splendid, TX
Section I--to be completed by attending physician or hospital patient
administrator. You are responsible for reviewing or typing in the information
provided by the physician or patient administrator.
Mark "X" in the appropriate box "Individual was: Outpatient,
Admitted, Dead on Arrival"
Mark "X" in the appropriate box "Civilian or Military," and
name of MTF
Enter hour, day, month, year of admission
Example: 0830, 21 June 8X
Enter hour, day, month, year of examination