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Get DA 7655 2015-2024

DOCTOR S PRINTED NAME 8. STATE LICENSE NUMBER 9. DOCTOR S ADDRESS TELEPHONE OR E-MAIL ADDRESS 10. DOCTOR S SIGNATURE DA FORM 7655 JUN 2015 APD LC v1. DEPARTMENT OF THE ARMY ARMED FORCES EYE AND VISION READINESS SUMMARY For use of this form see DA Pam 40-506 the proponent agency is OTSG* Privacy Act Statement AUTHORITY DoD Directive 6200. 04 DoD Instruction 6055. 1 E*O. 12196 AR 40-66 AR 40-501 and AR 600-8-101 PRINCIPLE PURPOSE S Department of Defense Force Health Protection policy requires the Services to conduct annual health assessments of military personnel including individual medical readiness IMR assessments. Visual performance and possession of required optical devices factor into IMR calculations to provide medical readiness data to unit commanders. Following an evaluation by an eye care provider Soldiers may use this form to capture spectacle prescription and visual performance data visual acuity for entry in the Medical Readiness Protection System MEDPROS. ROUTINE USE S None The DOD blanket routine uses may apply to this collection* DISCLOSURE Voluntary however failure to provide the information may result in delays in assessing refractive and vision health needs for military service. Information on this form may also be used to determine Vision Readiness Classification* 1. SERVICE MEMBER S NAME Last First Middle Initial 2. DATE OF BIRTH 4. UNIT OF ASSIGNMENT 5. UNIT ADDRESS 3. BRANCH OF SERVICE EXAMINATION RESULTS To the Doctor The patient who presented this form to you is a member of the United States Armed Forces. Please complete the information below to assist the Department of Defense DOD and your patient to meet medical readiness tracking requirements. The DOD will use the examination results on this form to determine your patient s fitness for prolonged duty without ready access to eye care. The DOD will not use the information on this form to address or document your patient s comprehensive ocular health or visual needs. DATE OF SPECTACLE RX YYYYMMDD 6. DATE OF VISION SCREENING YYYYMMDD 2 BEST CORRECTED DISTANCE VISUAL ACUITY 1 UNCORRECTED DISTANCE VISUAL ACUITY Right Eye 20/ Left Eye Both Eyes 3 IF 45 UNCORRECTED NEAR VISUAL ACUITY 4 IF 45 BEST CORRECTED NEAR VISUAL ACUITY 5 SPECTACLE PRESCRIPTION MINUS CYLINDER FORMAT IF NEAR VISION ONLY ANNOTATE IN BIFOCAL FORM Right Eye SPHERE CYLINDER - AXIS ADDITION PRISM Left Eye SPHERE 6 PUPILLARY DISTANCE FAR mm NEAR 7 Does the patient have any ocular condition s that may present problems in austere environments far removed from routine medical care YES If yes please state condition s NO 8 Will the patient require a 180-day supply of medication s to treat an ophthalmologic condition s If yes please provide medication s and dosage s 9 Has the patient undergone a refractive surgical procedure s in the past 7. DEPARTMENT OF THE ARMY ARMED FORCES EYE AND VISION READINESS SUMMARY For use of this form see DA Pam 40-506 the proponent agency is OTSG* Privacy Act Statement AUTHORITY DoD Directive 6200. 04 DoD Instruction 6055. 1 E*O. 12196 AR 40-66 AR 40-501 and AR 600-8-101 PRINCIPLE PURPOSE S Department of Defense Force Health Protection policy requires the Services to conduct annual health assessments of military personnel including individual medical readiness IMR assessments. .

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