CUI // PRVCY — DEMONSTRATION ENVIRONMENT · NOTIONAL DATA ONLY
Readiness Factory
Periodic Health Assessment
VIEW
Your annual Periodic Health Assessment
DD Form 3024 · Part A. Your medical, military, and last PHA record have been brought together before you start —
most items just need a look and a confirmation.
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NameSmith, Dana R.
Date of birth14 Jun 1994
SexFemale
DoD ID1234567890
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Periodic Health Assessment · Due 2 Apr 2026
Welcome back, Dana.
Your annual Periodic Health Assessment is how the Military Health System keeps your medical readiness current. Most of it is already filled in from your health record — your job is to check it and answer the handful of questions only you can answer.
15days until due
Due 2 Apr 2026
Last PHA completed 2 Apr 2025
What you’ll do
1
Confirm what we know
Read what your record already says and correct anything wrong.
2
Answer what we can’t know
A short set of questions about the last few weeks.
3
Review & sign
Check it over and submit. After that it’s locked.
Also due at your lab visit
HIV screening31 Jul 2026Ordered
Cholesterol screeningPast dueOrdered
Choose how you want to complete it
Recommended
Guided
We walk you through it in three steps, and skip every question that doesn’t apply to you.
See every section of Part A exactly as it appears on the form, and work through it in order.
All 10 sections, start to finish
Confirm and answer together, section by section
Best if you’d rather see the whole thing
You can switch paths at any time, and your answers carry over. Save and finish later from either one. Once you sign and submit, Part A is locked and goes to your health care team.
Smith, Dana R.PHA due in 15 days · 2 Apr 2026
1Part A: Your submission0 of 9 sections complete2Part B: Record ReviewAfter you submit — mostly automatic3Part C: MHA & ProviderYour care team completes this🔒Sign & CertifyRequires MHA
0 of 8 sections complete
Part A · Section I
Service Member Information and Demographics
Start by confirming your information. Under each item is where it came from: a lock means it’s from your official record and can’t be changed here; blue items are prefilled from your last PHA or health record — fix anything that’s wrong; anything marked not on file needs your answer. Then choose Verify & Continue.
Identity
Service and unit
Contact information
Emergency point of contact — no health or medical information is shared with this contact
Part A · Section II
Deployment Information
Your deployment history is prefilled from service records. Confirm or edit it, then answer the last question.
4Are you going to deploy within the NEXT 120 DAYS?
Answer required
Part A · Section III
Occupational Information
Confirm your occupational details, then answer the two duty questions.
3Does your military specialty require an operational duty physical exam (e.g., flight, jump, dive, missile, submarine, personnel reliability program, Special Forces)?
Answer required
4Are you currently enrolled in a medical surveillance/occupational health program (for example: hearing conservation, radiation health, healthcare worker monitoring, etc.)?
Answer required
Part A · Section IV
Medical Conditions
Confirm the conditions on your record, add any others, then work through the questions that only
you can answer. Items that came from your record are shown with their source; everything else defaults to
“does not apply” until you change it.
Question 1 · conditions since your last assessment
1Since your last health assessment, have you experienced any of the following health conditions, and if so what is your status?
These two came from your record. Confirm the status, adjust it, or remove the condition. Then open the full list to add any other.
Question 2 · conditions that required care or affected duty
2Since your last PHA, have you experienced any of the following health conditions that either required medical care or impacted your duty performance (or both) and if so, what is your status?
Nothing was flagged on your record here. Open the list and mark any that apply — everything defaults to “does not apply.”
Question 3 · profile or limited duty
3For each condition, are you currently on any profile or limited duty (LIMDU) for that condition?
We’ll ask this only for the conditions you marked “yes” above.
Questions 4–7 · burn pit & airborne hazards
4Have you been based or stationed at a location where an open burn pit was used?
NoSourceYour last PHA · 2 Apr 2025
5Have you been exposed to toxic airborne chemicals or other airborne contaminants?
NoSourceYour last PHA · 2 Apr 2025
6Are you enrolled in the Airborne Hazards and Open Burn Pit Registry?
Answer required
7If you are eligible, do you elect to enroll in the Airborne Hazards and Open Burn Pit Registry?
Answer required
Questions 8–9 · surgery
8Have you had any surgery since your last PHA?
Answer required
9What was the condition(s) for which you had surgery and the type of surgery? Your record shows the first one — confirm or edit it, and add up to two more.
Condition and type are coded to ICD-11 / SNOMED CT in the live build.
Questions 10–17 · recommended surgery, equipment, and profiles
10.aSince your last PHA, has a health care provider recommended surgery(s) that you have not had (whether you are planning to have it or not)?
Answer required
11.aDo you currently require hearing aids, special medical supplies, CPAP, adaptive equipment, assistive technology devices, and/or other special accommodations?
Answer required
12.aDo you currently have a waiver or profile for any part of your Service’s physical fitness test? (Skip if Coast Guard or Other)
Answer required
12.b. Which component(s) of your physical fitness test are waived/profiled? Mark all that apply.
13.aDo you have any problems wearing a gas mask, ballistic helmet, body armor, and/or chemical/biological protective garments?
Answer required
14.aHave you ever been told by a health care provider that you SHOULD NOT receive a vaccine/immunization for medical reasons?
Answer required
15.aAre you CURRENTLY on a permanent profile, permanent limited duty (PLD), waiting on a MOS/Medical Retention Board (MMRB) decision, or being referred to a Medical Evaluation Board (MEB), or Physical Evaluation Board (PEB) (Army, Navy, Marine Corps, Coast Guard) or Do you CURRENTLY have an Assignment Limitation Code C (Air Force)?
Answer required
16.aAre you on a temporary profile or temporary limited duty (LIMDU/TLD)?
Answer required
17During the PAST 2 YEARS, how many times have you been placed on a temporary profile or on temporary limited duty (LIMDU/TLD)?
Answer required
Part A · Section V
Individual Medical Readiness
Confirm what’s on your record, then answer the readiness questions only you can answer.
Question 1–2 · allergies
1Do you have any allergies (not including seasonal or pet allergies)?
YesSourceMHS GENESIS allergy list · Penicillin
2What are your allergies? Mark all that apply.
Penicillin came from your record and is checked below — uncheck it if it no longer applies, and add any others.
Question 3 · medical warning tags
3Do you have red medical warning “dog tags,” and are they current? Some examples of what may require a red dog tag: Allergies to antibiotics and/or other medications/immunizations, diabetes, special medication requirements, sensitivity to bug bites, and sickle cell disease.
Answer required
Questions 4–6 · corrective lenses
4Do you wear corrective lenses (glasses or contacts)?
YesSourceYour last PHA · 2 Apr 2025
5How many pairs of serviceable glasses do you have with a current prescription (verified within last 2 years)?
Answer required
6Do you have gas mask inserts with a current prescription (verified within last 2 years)?
Answer required
Part A · Section VI
Behavioral Health
These questions are yours to answer. Your responses go to your health care team so they can support you — there are no scores and no pass or fail here. If anything is hard to answer, you can ask to talk with someone using the requests at the end of this section.
Question 1 · life stressors
1.aOver the PAST MONTH, which major life stressors, if any, have you experienced that are a cause of significant concern or make it difficult for you to do your work, take care of things at home, or get along with other people? Mark all that apply.
Answer required
1.bAre you currently in treatment or getting professional help for these concerns?
Answer required
Question 2 · mental health care in the past year
2.aIn the PAST YEAR did you receive care for any mental health condition or concern such as, but not limited to, post-traumatic stress disorder (PTSD), depression, anxiety disorder, alcohol abuse, or substance abuse?
Answer required
Question 3 · current medications
3What prescription or over-the-counter medications (including herbals/supplements) for sleep, pain, combat stress, or a mental health concern are you CURRENTLY taking?
Answer required
Your last PHA listed: Melatonin. Choose “Please list” to confirm or edit it.
Medications are coded from RxNorm / RxTerms in the live build (search-as-you-type).
Question 4 · gambling
4.aIn the past 12 months, have you gambled?
Answer required
4.bDuring the past 12 months, have you become restless, irritable, or anxious when trying to stop/cut down on gambling?
Answer required
4.cDuring the past 12 months, have you tried to keep your family or friends from knowing how much you gambled?
Answer required
4.dDuring the past 12 months, did you have such financial trouble as a result of your gambling that you had to get help with living expenses from family, friends, or welfare?
Answer required
Question 5 · alcohol use
5.aHow often do you have a drink containing alcohol?
Answer required
5.bHow many drinks containing alcohol do you have on a typical day when you are drinking?
Answer required
5.cHow often do you have six or more drinks on one occasion?
Answer required
Question 6 · experiences and reactions
Have you ever had any experience that was so frightening, horrible, or upsetting that, in the PAST MONTH, you:
6.aHave had nightmares about it or thought about it when you did not want to?
Answer required
6.bTried hard not to think about it or went out of your way to avoid situations that remind you of it?
Answer required
6.cWere constantly on guard, watchful, or easily startled?
Answer required
6.dFelt numb or detached from others, activities, or your surroundings?
Answer required
6.eFelt guilt or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?
Answer required
Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each question carefully and check the box for how much you have been bothered by that problem in the LAST MONTH. Please answer all items.
6.wHow difficult have these problems (6.f. through 6.v.) made it for you to do your work, take care of things at home, or get along with other people?
Answer required
Question 7 · mood over the last 2 weeks
Over the LAST 2 WEEKS, how often have you been bothered by the following problems?
7.iHow difficult have these problems (7.a. through 7.h.) made it for you to do your work, take care of things at home, or get along with other people?
Answer required
Questions 8–11 · requests
8Would you like to schedule an appointment with a health care provider to discuss any health concerns?
Answer required
9Are you interested in receiving information or assistance for a stress, emotional, or alcohol concern?
Answer required
10Are you interested in receiving assistance for a family or relationship concern?
Answer required
11Would you like to schedule a visit with a chaplain, mental health care provider, or a community support counselor?
Answer required
Part A · Section VII
Family History and Lifestyle
This is the longest section. Where your record already knows something — family history, your medication and supplement lists — it’s filled in for you to confirm or change. The rest are quick lifestyle questions.
Question 1 · overall health
1Overall, how would you rate your health during the PAST MONTH?
Answer required
Questions 2–5 · family history
2To the best of your knowledge, do or did any of the following blood relatives — parents, grandparents, brothers, or sisters — ever have any of the following medical problems? Mark all that apply.
A cancer history came from your record. Confirm or change it, then use the grids below to say which relatives.
Answer required
3Which of the following family members has/had the history of cancer? Mark all that apply.
4Which of the following family members has/had the history of heart-related conditions? Mark all that apply.
5Which of the following family members has/had the history of diabetes? Mark all that apply.
Questions 6–7 · physical activity
6I participate in moderate intensity physical activities at least 2 ½ hours, or a combination of moderate and vigorous aerobic activities, for at least 75 minutes per week.
Answer required
7In a typical week, I do physical activities specifically designed to STRENGTHEN my muscles such as lifting weights or doing calisthenics: Day(s) per week
Answer required
Question 8 · routine medications
8What prescriptions or over-the-counter medications (including Tylenol, Advil, Sudafed, and/or aspirin) are you CURRENTLY taking for health problems on a ROUTINE BASIS? Do NOT include vitamins or nutritional supplements.
Answer required
Your record lists: Ibuprofen. Choose “List medications” to confirm or edit it.
Medications are coded from RxNorm / RxTerms in the live build.
Questions 9–10 · dietary supplements
9Which of the following products, or products marketed for the following purposes, have you taken, even once, since your last PHA? Mark all that apply.
Multi-Vitamins and Vitamin D came from your record.
Answer required
10Since your last PHA, how often did you take:
Question 11 · nutrition
11Think about the PAST 30 DAYS. How often did you eat or drink the following foods or beverages?
Question 12 · cholesterol
12Have you had a cholesterol check by a doctor, nurse, or other health care professional within the PAST 5 YEARS?
Answer required
This question is shown only for Traditional Guard/Reserve, IRR, or ING members. It’s hidden for your active-duty status.
Questions 13–16 · tobacco
13.aIn the PAST 30 DAYS, which of the following products have you used on at least one day? Mark all that apply.
Answer required
13.bHow long have you been using tobacco products?
Answer required
13.cHow often do you smoke tobacco (for example cigarettes, cigars, pipes, or hookah)?
Answer required
13.dHow many packs per day do you smoke?
Answer required
14Are you interested in quitting tobacco?
Answer required
15Which of the following best describes your past tobacco use?
Answer required
16Are you regularly exposed to secondhand smoke (for example, at home, in a vehicle, or in the workplace)?
Answer required
Questions 17–19 · sleep and weight
17During the LAST 2 WEEKS, how many hours of sleep did you get on most days?
Answer required
18During the LAST 2 WEEKS, have you felt impaired or unable to adequately perform your duties due to sleepiness or poor quality sleep?
Answer required
19Have you had any unexplained weight loss or gain since your last PHA?
Answer required
Questions 20–23 · sexual health
20Sexually transmitted infection (STI) risk factors — choose the answer that fits your risk.
Risk factors include: a new sex partner in the past 90 days; more than one sex partner in the past 12 months; a sex partner who has other partners; a sex partner with a sexually transmitted infection; inconsistent condom use; exchanging sex for money or drugs; or a diagnosed STI in the past 12 months.
Answer required
21Have you had a syphilis, chlamydia, and gonorrhea test since your last PHA?
Answer required
Question 21 is shown for males who report an STI risk factor. It’s hidden for your demographics.
22Since your last PHA, what contraceptive methods, if any, have you and your partner(s) been using to prevent pregnancy? Mark all that apply.
I am not actively taking steps to prevent pregnancy as:
I am actively taking steps to prevent pregnancy, including:
With intercourse (mark all that apply):
Answer required
23In the last year, have you or your partner had a pregnancy scare, where you were not trying to get pregnant but were worried enough to use a home pregnancy test?
Answer required
Part A · Section VIII
Women’s Health
This section is shown because your record lists your sex as female. Confirm the screening items already on your record, then answer the questions only you can answer.
Question 1 · contraceptive counseling
1Do you wish to receive contraceptive counseling?
Answer required
Question 2 · pregnancy status
2Which of the following best describes you?
Answer required
Question 3 · surgical history
3Have you had a total hysterectomy (uterus and cervix removed)?
NoSourceMHS GENESIS surgical history
Question 4 · menstrual status
4Are you postmenopausal and no longer experiencing menstrual cycles?
Answer required
Question 5 · folic acid
5Are you currently taking folic acid or a vitamin containing folic acid?
Answer required
Question 6 · menstrual symptoms
6Do you have heavy and/or irregular menstrual cycles/pain or premenstrual syndrome (PMS)?
Answer required
Question 7 · urinary tract infections
7Do you have recurrent urinary tract infections (more than 3 in the past 12 months)?
Answer required
Question 8 · cervical cancer screening
8Have you had a Pap test (cervical cancer screening) within the PAST 3 YEARS?
YesSourceMHS GENESIS · Pap 15 Mar 2024
Questions 9–10 · Pap history
9Have you ever had an abnormal Pap test?
NoSourceMHS GENESIS cytology history
10Have you ever had a colposcopy, an excisional procedure (LEEP or Cold Knife Cone), or cryotherapy (freezing) on your cervix?
Answer required
12(If pregnant/may be pregnant, or a listed STI risk factor applies) Have you had a syphilis, chlamydia, and gonorrhea test since your last PHA?
Answer required
Question 13 · pregnancy history
13Do you have a history of gestational diabetes?
NoSourceYour last PHA · 2 Apr 2025
Part A · Section X
Other Medical
A few remaining items on pain, outside care, and anything not already covered.
Questions 1–2 · pain
1(PAIN SCALE) Rate the amount of pain you have had, on average, over the PAST 24 HOURS.
Answer required
2Are you receiving treatment for pain?
Answer required
Questions 3–4 · outside care
3Since your last PHA, have you received care or treatment for any medical and/or mental health condition(s) from a CIVILIAN or NON-MILITARY facility? This includes privately paid elective surgeries.
NoSourceHIE / claims · no civilian encounters found
4List the condition(s) treated and where the care was provided.
Question 5 · acknowledgment
I acknowledge I am responsible to report medical (including mental health) and health issues that may affect my readiness to deploy or fitness to continue serving in an active status in accordance with Department of Defense Instruction 6025.19, Individual Medical Readiness. As a condition of continued participation in military service, I must report significant health information to my chain of command. In addition, I will authorize and facilitate disclosures of all health information by any non-DoD health care provider(s) to the Military Health System (MHS) and/or to my respective Reserve Component.
Acknowledgment required
Questions 6–7 · anything else
6Are you concerned about any other health condition(s) or health risk exposures not already addressed?
Answer required
7Would you like to schedule an appointment with a health care provider to discuss any health concerns?
Answer required
Part A · Section XI
Separation and Retirement
One last question before you review and sign.
1Are you planning to separate or retire within the next year from Active Duty or Reserve Duty (activated for greater than 30 continuous days) or do you intend to file a claim for disability compensation with the Veterans Benefits Administration?
Answer required
Part A · Review
Review & sign
Confirm each section, then sign. After you submit, Part A is locked and goes to the health care team for review.
○I. Service Member Information and DemographicsIncomplete
○II. Deployment InformationIncomplete
○III. Occupational InformationIncomplete
○IV. Medical ConditionsIncomplete
○V. Individual Medical ReadinessIncomplete
○VI. Behavioral HealthIncomplete
○VII. Family History and LifestyleIncomplete
○VIII. Women’s HealthIncomplete
○X. Other MedicalIncomplete
○XI. Separation and RetirementIncomplete
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DD Form 3024 — official layout
Read-only · reflects your current answers · use your browser's print for a paper copy
Items marked “not yet answered” are still open in the guided steps.