This survey evaluates your health status and serves as your annual certification of physical condition as required by the Title 10 of the United States Code, Section 10206, and applicable Service regulations. The information reported on this survey will be used:

• To verify your medical and dental readiness status.
• To advise your commander ONLY that you have completed this form and of your overall medical readiness status.
• To advise healthcare providers of changes in your physical or mental condition, without specifying what those changes are. Authorized healthcare providers may be advised of significant changes in your Physical Health, Mental Health, Stress & Environmental Issues, or Health Promotion activities. This advice will reflect Green, Amber, or Red indicators and what aspect of your health status has changed (similar to the feedback report you receive upon completion of this survey). Specific responses to questions are not provided.
• To support research regarding force health protection, wellness, and occupational health and safety.
• The information provided in this survey is guarded under the provision of the Health Insurance Portability and Accountability Act (HIPAA) and the Privacy Act, and may not be released without your express, written consent. All questions are strictly confidential and will not be disclosed.

Please type in your Social Security Number and the Date and Month of your birth in the fields below, then click the "enter" button to register for the survey questions.

Social Security No.
Date of Birth
9 Digits, no dashes
Date
Month

NO INDIVIDUAL OR PERSONAL INFORMATION WILL BE DISCLOSED.

NO INDIVIDUAL, CLINICAL, OR MEDICAL DATA WILL BE RELEASED OR REPORTED OUTSIDE MEDICAL CHANNELS.

THIS SURVEY IS TOTALLY CONFIDENTIAL.


Disclosure of this information is required by Title 10, Chapter 51, Section 1004 of the United States Code. Giving false information concerning current health status is a punishable offense and can result in administrative action. In accordance with applicable service regulations, each member is responsible for promptly reporting any disease, injury, operative procedure, or hospitalization not previously reported to his or her commander or supervisor.