Adobe / NEC / OR ACUTE SYMPTOMS / LEAST WEEKLY / /
Country
United States / / /
Facility
FACILITY ADDRESS / Any Hospital / CLINIC FOR ACUTE ASTHMA DURING THE PAST YEAR / / /
IndustryTerm
accompanied family travel / travel limitations / family travel review process / /
MedicalCondition
Special interventionist Speech Delay / Nighttime asthma / bronchitis / IS REQUIRED AND ATTACHED AUTISM SPECTRUM DISORDER / INTERMITTENT ASTHMA / asthma / pneumonia / cancer / Attention Deficit Disorders / THERE ANY TRIGGERS FOR THE FAMILY MEMBER'S ASTHMA ATTACKS / HISTORY ASSOCIATED WITH ASTHMA ATTACKS / bronchiolitis / Allergic Rhinitis / AIDS / Frequent nighttime asthma / IT A PREMATURE BIRTH / FAMILY MEMBER EVER EXPERIENCED UNCONSCIOUSNESS OR SEIZURES ASSOCIATED WITH ASTHMA ATTACKS / croup / FAMILY MEMBER BEEN HOSPITALIZED FOR PULMONARY DISEASE / /
Pentagon / Executive Services Directorate / U.S. Government / OF SERVICE / Information Management Division / United States Marine Corps / MEDICARE / SOCIAL SECURITY ADMINISTRATION / NATIONAL GUARD / Military Service / Any Hospital / Department of Defense / E-6 ARMY / Suitability Screening Office / FAMILY MEMBER MISSED SCHOOL / PRIVACY ACT STATEMENT AUTHORITY / /
Person
STAMP EFMP / Shelly R. Brown / David H. Brown / Case / / /
Position
PSYCHOLOGIST / PSYCHIATRIST / Advisor / SOCIAL WORKER / NEUROSURGEON / GENERAL SURGEON / developmental pediatrician / DIETARY/NUTRITION SPECIALIST / RESPIRATORY THERAPIST / privacy/HIPAA coordinator / GYNECOLOGIST / PHYSICAL THERAPIST / OCCUPATIONAL THERAPIST / NEUROLOGIST / Screening Coordinator / Official / CARDIOLOGIST / CARDIAC/THORACIC SURGEON / MANAGER CONTACT INFORMATION / Coordinator / CASE MANAGER / pediatrician / PSYCHIATRIST NURSE / SPEECH AND LANGUAGE PATHOLOGIST / AUDIOLOGIST / Worker / /
Product
Zyrtec / Albuterol / ZTE C78 Cellular Phone / Daily Synapsis injections / prednisolone / Flovent / OFTEN DOES THE FAMILLY MEMBER USE HIS/HER RESCUE INHALER OR NEBULIZER MEDICATION / Inh / Singulair / prednisone / /
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.