DA Form 5669 PDF: Preventive Medicine Counseling Record

DA Form 5669 PDF: Preventive Medicine Counseling Record – U.S. Army Soldiers, commanders, and military healthcare providers often need clear guidance on DA Form 5669, officially titled the Preventive Medicine Counseling Record. This form plays a critical role in the Army’s HIV management program. It documents that a Service member who tests positive for HIV has received and understands essential counseling on preventing transmission, protecting their health, and fulfilling military responsibilities.

Whether you’re a Soldier newly diagnosed, a Public Health Nurse (HIV PHN), a commander, or simply preparing for medical readiness, this article provides everything you need: the form’s purpose, when it’s required, step-by-step completion guidance, official download link, and related policies under AR 600-110. All information is drawn from current, trusted U.S. Army sources as of 2026.

What Is DA Form 5669?

DA Form 5669 (dated JUL 2012) is a one-page Department of the Army form used exclusively to record preventive medicine counseling for Service members who test positive for HIV infection.

  • Proponent: DCS, G-1 (Deputy Chief of Staff, Personnel)
  • Prescribed by: AR 600-110, Identification, Surveillance, and Administration of Personnel Infected with Human Immunodeficiency Virus (HIV)
  • Previous version: DA Form 5669-R (DEC 87) is obsolete

The form ensures Soldiers receive face-to-face counseling on HIV transmission risks, prevention methods, personal responsibilities, and Army-specific implications (such as non-deployability rules and medical follow-up). It is not a general counseling tool—use DA Form 4856 for commander counseling.

Why Is DA Form 5669 Important?

HIV counseling protects the individual Soldier, their unit, sexual partners, and the force as a whole. The form:

  • Documents that the Soldier understands transmission risks (even with undetectable viral load).
  • Records acknowledgment of specific preventive measures.
  • Supports medical surveillance, confidentiality, and compliance with UCMJ and Army policy.
  • Triggers required follow-on actions, including commander counseling (DA Form 4856) and annual Periodic Health Assessments (PHA).

Failure to complete or properly store the form can affect medical readiness, PCS moves, and career management.

When Is DA Form 5669 Required?

Use DA Form 5669 in these situations (per AR 600-110):

  • Immediately after a Soldier receives official notification of a confirmed positive HIV test (Western Blot or FDA-approved equivalent).
  • At diagnosis and as directed by the HIV Program Director/Coordinator (PHN).
  • Upon PCS, change of command (in coordination with new HIV PHN), or as required for Reserve/Guard Soldiers.
  • ARNG and USAR Soldiers (unless activated) complete it with annual fit-for-duty evaluations.

The HIV Program Coordinator (usually a Public Health Nurse) performs the initial preventive medicine counseling before the commander’s counseling.

Step-by-Step: How to Fill Out DA Form 5669?

The form has two main parts. The counselor (typically the HIV PHN) completes most of Part I from official records or the Soldier’s ID card.

Part I – Patient Information

  • A–F: Soldier’s name (Last, First, MI), DOB, grade, sponsor name, unit, and location.
  • G: Date of diagnosis (YYYYMMDD).
  • H–I: Date/time and location of counseling session.
  • J: Counselor’s name, grade/corps, and title/signature.

Part II – Patient Counseling Acknowledgment

The Soldier reads (or has explained) a detailed list of statements covering:

  • Understanding of positive HIV test and lifelong infection.
  • No cure; potential transmission via blood, semen, vaginal fluids, breast milk (even if undetectable).
  • Prohibition on donating blood/products, sperm, breast milk, tissues, or organs.
  • Non-deployability, TDY OCONUS restrictions, and possible career impacts.
  • Obligation to notify sexual/needle-sharing contacts (starting 3 months before last negative test).
  • Safer sex practices, condom/dental dam use, and partner notification requirements.
  • Avoiding sharing razors/toothbrushes and covering wounds.
  • Notifying medical/dental providers of HIV status.
  • Avoiding live-virus vaccines (e.g., MMR, varicella, yellow fever).
  • Family planning discussions with infectious disease physician.
  • Compliance with medical management, evaluations every 6 months (Active Duty) or annually (RC unless activated), and PHA.
  • Contacting HIV PHN before PCS, ETS, or retirement.

The Soldier signs and dates in block O. The counselor signs in block P.

Tip: The counseling must be private, face-to-face, and allow time for questions. The Soldier must acknowledge understanding all listed responsibilities.

Official DA Form 5669 PDF Download

Download the current fillable DA Form 5669 here (direct from Army Publishing Directorate):
https://armypubs.army.mil/pub/eforms/DR_a/pdf/DA%20FORM%205669.pdf

Always use the official PDF from armypubs.army.mil for the most current version.

Storage, Confidentiality & Transfer Rules

  • Maintained in a locked cabinet by the HIV Program Coordinator (PHN) per AR 600-110.
  • Commander receives a copy (eyes-only) along with DA Form 4856.
  • Upon PCS: Forward to gaining HIV PHN via secure/encrypted methods.
  • Upon ETS/retirement: Destroy the form.
  • Strict Privacy Act protections apply—disclosure is voluntary, but failure to provide info may result in incorrect records.
  • AR 600-110 (22 April 2014, still current): Full policy on HIV testing, surveillance, counseling, and administration.
  • DA Form 4856: Commander’s developmental counseling (completed after DA Form 5669).
  • Periodic Health Assessment (PHA): Required annually for HIV-positive Soldiers.
  • Other references: AR 40-501 (Standards of Medical Fitness), HRC HIV Manager guidance.

Frequently Asked Questions (FAQs)

Q: Can I refuse the counseling?
No. It is a required medical and administrative step under AR 600-110.

Q: Does this form affect my security clearance or career?
It is handled with strict confidentiality. Career impacts (e.g., non-deployability) follow medical and personnel policy, not the form itself.

Q: What if I’m in the Army National Guard or Reserve?
The same form applies; counseling frequency may differ unless activated.

Q: Where can I get help filling it out?
Contact your installation HIV Program Coordinator/Public Health Nurse.

DA Form 5669 ensures every HIV-positive Soldier receives clear, consistent preventive medicine counseling that protects health, supports readiness, and complies with Army standards. Proper use of this form, combined with commander counseling (DA Form 4856) and ongoing medical care, helps Soldiers continue serving while preventing transmission.

For the latest official guidance, always refer to AR 600-110 and the Army Publishing Directorate. If you need the form or have questions, reach out to your local HIV PHN or medical provider.

Official Download: DA Form 5669 PDF