k. SF 520, Electrocardiographic Record Baseline and all subsequent electrocardiograms.
l. SF 545, Laboratory Report Display Backing sheet for mounting SFs 546 through 557 in chronological order.
m. DD Form 771, Eyewear Prescription
n. DD Form 6490/1, Visual RecordNo longer required, but keep previously completed forms.
o. NAVMED 6224/1, TB Contact/Converter Follow-up.
p. DD Form 1141, Record of Occupational Exposure to Ionizing Radiation
q. DD Form 2215, Reference Audiogram Baseline audiogram only.
r. DD Form 2216, Hearing Conservation Data
s. OPNAV 5100/15, Medical Surveillance Questionnaire
t. NAVMED 6260/5, Periodic Health Evaluation, Navy Asbestos Medical Surveillance Program.
u. NAVMED 6100/1, Medical Board Report Cover Sheet
v. NAVMED 6100/2, Medical Board Statement of Patient-Attached to corresponding NAVMED 6100/1.
w. NAVMED 6100/3, Medical Board Certificate Relative to a PEB Hearing Attached to corresponding NAVMED 6100/1.
x. NAVMED 6120/1, Competence For Duty Examination
y. NAVMED 6120/3, Annual Certificate of Physical Condition
z. NAVMED 6150/2, Special Duty Medical Abstract
aa. NAVMED 6150/4, Abstract of Service and Medical History
bb. NAVMED 6420/1, Report of All Diving Accidents
cc. DD Form 877, Request for Medical/Dental Record or Information
dd. DD Form 2005, Privacy Act Statement - Health Care RecordsOne copy signed by the service member must be filed in each treatment record jacket.
ee. OPNAV 5211/9, Record of Disclosure - Privacy Act of 1974
NOTE: Not all the above forms will be required for every record.
a. NAVPERS 5510/1, Record Identifier for Personnel Reliability ProgramTopmost form.
b. SF 600, Chronological Record of Medical CareAll nonspecial SFs 600 shall be filed (grouped) together immediately below NAVPERS 5510/1, if required.
c. SF 558, Emergency Care and Treatmentinterfiled with the nonspecial SFs 600 since these forms document similar care. SF 558 shall be filed immediately above the SF 600 containing the last dated entry prior to the date on the SF 558.
d. SF 513, Consultation SheetFiled immediately below the SF 600 or SF 88 to which it pertains.
e. SF 502, Narrative Summary (Clinical Resume)
f. SF 539, Abbreviated Medical Record
g. SF 511, Vital Signs Record
h. SF 512, Plotting Chart
i. SF 512A, Plotting ChartBlood Pressure
j. SF 516, Operation Reportk. SF 517, Anesthesia SF l. 518, Blood or Blood Component Transfusion m. SF 522, Request for Administration of Anesthesia and for Performance of Operations and Other Procedures n. SF 524, Radiation Therapy o. SF 525, Radiation Therapy Summary p. SF 526, Interstitial/Intercavity Therapy q. SF 527, Group Muscle Strength, Joint R.O.M., Girth and Length Measurements r. SF 529, Muscle Function by Nerve Distribution: Face, Neck and Upper Extremity s. SF 529, Muscle Function by Nerve Distribution: Trunk and Lower Extremity t. SF 530, Neurological Examination u. SF 531, Anatomical Figure v. SF 533, Prenatal and Pregnancy w. SF 541, Gynecologic cytology x. SF 602, Syphilis Record y. NAVMED 6150/3, Sick Call Treatment RecordNo longer required, but keep previously completed forms. Forms g through w are filed in the health record when the procedures are competed in conjunction with outpatient care. No other forms or documents shall be incorporated in the military health (medical) treatment