Okafor, Jamal T. · sample record · SSN •••-••-4417 · SEPARATIONSeparation medical assessment · releases a copy to the VA
Prescribed by PL 103-160 · Separation / Retirement
Section I · Member Self-Report
A comprehensive medical assessment at separation or retirement, covering the period since your last assessment or physical. A copy is released to the Department of Veterans Affairs — accurate answers help your VA claim. Disclosure is voluntary, but omissions may delay a disability claim.
Items 1–9 · Identity (prepopulated — confirm)
Item 10 · Overall health
10Compared to my last medical assessment / physical examination, my overall health is:
Required
Items 11–17 · Health since last assessment
11Since your last assessment, have you had any illnesses or injuries that caused you to miss duty for longer than 3 days?
Required
12Since your last assessment, have you been seen or treated by a health care provider, admitted to a hospital, or had surgery?
Required
13Have you suffered any injury or illness while on active duty for which you did not seek medical care?
Required
14Are you now taking any medications?
Required
15Do you have any conditions that currently limit your ability to work in your primary military specialty, or require geographic or assignment limitations?
Required
16Do you have any dental problems?
Required
17Do you have any other questions or concern about your health?
Required
Item 18 · VA disability intent
18At the present time, do you intend to seek Department of Veterans Affairs (VA) disability?
Required
Answering "Yes" prompts a separation physical examination if your last exam is over 12 months old or there are new signs/symptoms.
Item 19 · Certification
I certify that the information provided above is true and complete to the best of my knowledge.
Signature captured at sign-off · CAC / PKI
Answer items 10–18 to continue.
Items 20–25 · Privileged provider
Section II · Provider Assessment
Completed by an individually privileged health care provider. Covers, at minimum, the period since the member's last assessment or their call/order to active duty.
Documentation reminder: a response of "Worse" to Item 10, or "Yes" to Items 11, 12, or 14–18, should be documented in the member's medical or dental record.
Item 20 · Provider comments (all patient complaints must be addressed)
Item 21 · Referral
21Was patient referred for further evaluation?
Required
Item 22 · Purpose of assessment
22Purpose of this assessment
Required
"Separation" includes discharge and release from active duty, including release of National Guard and Reserve personnel called or ordered to active duty.
