DoDMERB Questionnaire - Class of 2027

(Mark a collumn)

Yes No Question

1. Have you ever taken or do you now take medication (over the counter or prescription)?

List Each Medication Why did you take it Do you still take it? If not, when did you stop?

1

2

3

10

2. Have you ever had or do you now have allergies?

3. Double vision

4. Detached retina or surgery to repair a detached retina

5. Keratoconus, glaucoma, cataracts or surgery for cataracts

6. Vision correction procedure such as Lasik, PRK, or lens implant

7. Night blindness

8. Any other eye condition, injury, or surgery/procedure

9. Cholesteatoma

10. Ear drum perforation or tubes inserted into the ear drum(s) in the past 12 months