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INSTRUCTIONS FOR COMPLETING DD FORM 2792, FAMILY MEMBER MEDICAL SUMMARY GENERAL. Items 11.a. - h. Mark (X) all services being provided to the family member.
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Document Date: 2011-08-16 09:12:20

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City

Washington / DC / /

Company

Adobe / NEC / OR ACUTE SYMPTOMS / LEAST WEEKLY / /

Facility

FACILITY ADDRESS / CLINIC FOR ACUTE ASTHMA DURING THE PAST YEAR / /

IndustryTerm

accompanied family travel / family travel review process / travel limitations / /

MedicalCondition

pneumonia / cancer / Attention Deficit Disorders / THERE ANY TRIGGERS FOR THE FAMILY MEMBER'S ASTHMA ATTACKS / Nighttime asthma / bronchitis / HISTORY ASSOCIATED WITH ASTHMA ATTACKS / bronchiolitis / IS REQUIRED AND ATTACHED AUTISM SPECTRUM DISORDER / AIDS / Frequent nighttime asthma / INTERMITTENT ASTHMA / IT A PREMATURE BIRTH / FAMILY MEMBER EVER EXPERIENCED UNCONSCIOUSNESS OR SEIZURES ASSOCIATED WITH ASTHMA ATTACKS / croup / FAMILY MEMBER BEEN HOSPITALIZED FOR PULMONARY DISEASE / asthma / /

MedicalTreatment

CONTINUOUS POSITIVE AIRWAY PRESSURE / complementary therapies / DIALYSIS / INSULIN PUMP / /

Organization

SOCIAL SECURITY ADMINISTRATION / ARMY NAVY / Pentagon / NATIONAL GUARD / Executive Services Directorate / U.S. Government / OF SERVICE / Information Management Division / Military Service / Department of Defense / Suitability Screening Office / FAMILY MEMBER MISSED SCHOOL / United States Marine Corps / PRIVACY ACT STATEMENT AUTHORITY / MEDICARE / /

Position

PSYCHOLOGIST / PSYCHIATRIST / Official / CARDIOLOGIST / Advisor / CARDIAC/THORACIC SURGEON / SOCIAL WORKER / NEUROSURGEON / MANAGER CONTACT INFORMATION / Coordinator / GENERAL SURGEON / developmental pediatrician / CASE MANAGER / DIETARY/NUTRITION SPECIALIST / RESPIRATORY THERAPIST / pediatrician / PSYCHIATRIST NURSE / privacy/HIPAA coordinator / GYNECOLOGIST / SPEECH AND LANGUAGE PATHOLOGIST / EFMP/SNIAC/Screening Coordinator / PHYSICAL THERAPIST / OCCUPATIONAL THERAPIST / AUDIOLOGIST / NEUROLOGIST / Screening Coordinator / /

Product

prednisolone / OFTEN DOES THE FAMILLY MEMBER USE HIS/HER RESCUE INHALER OR NEBULIZER MEDICATION / prednisone / Albuterol / ZTE C78 Cellular Phone / /

ProgrammingLanguage

DC / /

Technology

DIALYSIS / /

URL

http /

SocialTag