A Table of all Navy Medicine forms

Part 1: Record of preventative medicine and occupational health

NAVMED 6150This is the summary of the care form. It should always be on top and in the front of the records form.
SF 601This is the form that has to deal with Immunization records.
NAVMED 6000/2This is a chronological record of HIV testings
DD 771This form is the prescription glasses and eyewear form.
NAVMED 6490/1This is for a visual record.
NAVMED 6470/10This form is a record of occupational exposure to ionizing radiation.
NAVMED 4670/11This form is used to record the exposure of ionizing radiation from internally deposited radionuclide.
DD 2215This is the form for referencing the audiogram.
DD 2216This is a form for hearing the conversation data.
NAVMED 6224/1This form is for TB contact converter follow-up.
NAVMED 6260/5This form is used for the asbestos medical surveillance program.
DD 2493-1This form is for asbestos exposure and part of the first part of the initial medical questionnaire.
DD 2493-1Not many changes here, but it’s also the same as above. This form is for asbestos exposure and part of the second part called the periodic medical questionnaire.
OPNAV 5100/15This is the form that covers the medical surveillance questionnaire.

Part 2: Section A

NAVPERS 5510/1These are the record identifiers for the Personal Reliability Program (PRP).
SF 558This is the form for medical records that consist of emergency care and treatment record of ambulance care.
SF 600Here we have the HREC which is a chronological record of medical care.
SF 513This is the form for the medical record consultation sheet.
DD 2161This is the referral for civilian medical care.

Part 2: Patient deceased records

Attestation sheetThis is the form that serves as a declaration or statement of certain information that is true.
DD 2604This is the form that’s also known as the certification of death.
SF 503This is the autopsy protocol form.
SF 523This is the form that holds the authorization of autopsy.
SF 523AThis is the form that handles the disposition of the body.
SF 523BThis is the form that contains authorization for tissue donation.

Part 2: Section B, Inpatient care, ambulatory surgeries, etc.

NAVMED 6300/5This form serves as the inpatient admission disposition record form.
SF 502This is the basic summary narrative of the visit.
SF 539This is the abbreviated medical record.
SF 509This is the form that has all the progress notes in it.
SF 516This is the form that has the operation reports in it.
SF 600This is the record of medical care that’s in chronological order.
SF 517This is the record for anesthesia operations.
SF 522This is a form that’s a request for the administration of anesthesia.
SF 233This is the record for prenatal and pregnancy civilian medical care notes.
DD 602This is the patient’s evaluation tag.

Part 3: Medical record forms

NAVMED 1300/1This is the medical and dental overseas screening review form for active duty and their dependents.
NAVPERS 1300/16This is the form for the report of suitability for overseas assignments.
NAVMED 6100/1This is the medical board report cover sheet.
NAVMED 6100/2This is the medical board statement of the patient form.
NAVMED 6100/3This is the medical board certificate.
NAVMED 6100/5This is the abbreviated temporary limited duty report form.
SF 2824CThis is the form for the physician statement for the employee disability retirement report.
SF 47This is the physical fitness inquiry for motor vehicle operators form.
SF 78This is the certificate of medical examinations form.
DD 2807This is the report of medical history.
DD 2808This is the report for medical examinations.
NAVMED 6120/2This is the form for the officer physical examination special questionnaire.
NAVMED 6120/3This is the annual certificate physical condition form.
NAVMED 6150/4This is the abstract of service and medical history form.
NAVJAG 5800/10This is the injury report form.
NAVJAG reportThis is the report from the JAG.
NAVPERS 1754/1This is an exceptional family member program application.
DD 2569This is a third-party collection program.
Living willThis is a living will with the medical power of attorney.
OPNAV 5211/9This is the record of disclosure and it is in compliance with the Privacy Act of 1974.
DD 877This is the form for requesting medical or dental records.
DD 2005This is the Privacy Act Statement.
DNA AnalysisThis is the deoxyribonucleic acid analysis sample pouch.

Part 4: Special forms, inside the back cover

SF 217This is the epilepsy medical report.
SF 515This is the tissue examination report.
SF 519AThis is the radiographic report.
SF 519BThis is the radiologic consultation request form.
SF 519This is the medical record-radiographic report.
SF 518This is the blood component transfusion report.
SF 520This is the electrocardiogram request form.
SF 524This is the radiation therapy form.
SF 525This is the radiation therapy summary form.
SF 526This is the interstitial/intercavity therapy form.
SF 527This is the group muscle strength, joint ROM, girth, and length measurements form
SF 528This is the muscle function by nerve distribution which includes the face, neck, and upper extremities.
SF 529This is the muscle function by nerve distribution which includes the trunk and lower extremities.
SF 53This is the neurological examination form.
SF 531This is the anatomical figure form.
SF 541This is the gynecologic cytology from.
SF 545This is the lab report display form.
SF 546-557These are lab report forms.
SF 559This is the allergen extract prescription for new and refills.
SF 560This is the electroencephalogram request and history form.
SF 511This is the vital signs record form.
SF 512This is the plotting chart form.
SF 512AThis is the blood pressure plotting chart form.

Author: John

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