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U.S. DOD Form dod-da-5181 SCREENING NOTE OF ACUTE MEDICAL CARE For use of this form see AR 40-66 the proponent agency is the Office of The Surgeon General. TIME PATIENT DEPARTS UNIT From DD Form 689 DATE YYYYMMDD SCREENER LOCATION TIME PATIENT ARRIVES BARRACKS CHIEF COMPLAINT PATIENT RESIDENCE TIME ENCOUNTER BEGINS DURATION VITAL SIGNS TEMPERATURE OFF POST POST HOUSING PULSE FIRST VISIT FOR THIS COMPLAINT YES NO TRANSIENT YES ALLERGIES BP RESP .

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