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MEDICAL HISTORY AND EXAMINATION (U.S. Department of State)

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The US Department of State (DOS) or the State Department, is the government official division that advises the President and performs international relations. Equivalent to the outside service of different nations, it was built up in 1789 as the country's first official department.

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MEDICAL HISTORY AND EXAMINATION
FOR INDIVIDUALS AGE 12 AND OLDER
PRIVACY ACT NOTICE
AUTHORITIES: The information is sought pursuant to the Foreign Service Act of 1980, as amended (Title 22 U.S.C.4084).
PURPOSE: The information solicited from this form will assist in making a medical clearance decision for individuals eligible to participate in the
Department of State Medical Program while assigned abroad. (16 FAM 100 - 200)
ROUTINE USES: Unless otherwise protected by law, the information solicited on this form may be made available to appropriate agencies, whether
Federal, state, local, or foreign, for law enforcement and other authorized purposes. The information may also be disclosed pursuant to court order.
More information on routine uses can be found in the System of Records Notice State-24, Medical Records.
DISCLOSURE: Providing this information is voluntary; however, not providing requested information may result in the failure of the individual to obtain
the requisite medical clearance pursuant to 16 FAM 211.
PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average one (1) hour per
response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or
documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB
control number. If you have comments on the accuracy of this burden estimate and /or recommendation for reducing it, please send them to:
M/MED/EX, Room L101 SA-1, U.S. Department of state, Washington, DC 20522
I. DEMOGRAPHIC INFORMATION
TO BE FILLED OUT BY EXAMINEE (OR PARENT)
DATE OF EXAM (mm-dd-yyyy)
1. Name of Examinee (Last, First, MI) 2. If Eligible Family Member, Name of Employee/Applicant
3. Date of Birth (mm-dd-yyyy) 5. Sex
Male Female
4. MED ID (if available)
6. Place of Birth
City
Country
7. Status
Spouse
Employee
New Family Member
(Spouse, Newborn, Adoption)
Applicant
Dependent Child
State
10. Purpose of Exam
Pre-Employment Exam
In-Service Exam
Separation Exam
Bureau of Medical Services, Room L101, SA-1, Washington, DC 20522-0102
*OMB APPROVAL NO. 1405-0068
EXPIRATION DATE: 10-31-2023
ESTIMATED BURDEN: 1 HOUR
U.S. Department of State
DS-1843
06-2020
Page 1 of 4
To the individual and/or health care provider completing the medical history review /exam: The Genetic Information Nondiscrimination Act of 2008 (GINA)
prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the
individual, except as specifically allowed by this law. To comply with this law we are asking that you NOT provide any genetic information when responding to
this request for medical information. 'Genetic Information' as defined by GINA, includes an individual's family medical history, the results of an individual's or
family members' genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a
fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive
services.
8. Agency of Employee/Applicant/Sponsor
STATE
FCS FASUSAID
U.S. Agency for Global Media
DoD Civilian DoD Contractor
Non-Foreign Service Agency Contracting Company
REA-WAE
11. Employment Status
Civil Service
Contractor
PSC Contractor
FS Officer
FS Specialist
LES
LNA
Fellow
Other
13. Telephone Number of examinee or parent of child < 18 y/o
(Where You can be Reached for the Next 90 days)
12. E-mail Address of examinee or parent of child < 18 y/o
(Where You can be Reached for the Next 90 days)
Primary:
Alternate:
Primary:
Alternate:
15. Post of Assignment and Estimated Dates of Arrival / Departure
a. Proposed Post
b. Present Post
EDD
EDA
(mm-dd-yyyy)
(mm-dd-yyyy)
14. Assignment Details (Check all that apply)
TDY (Regional hub or CONUS based)
Iraq - List Post
Afghanistan
Other ESCAPE Post(s) If yes, list
9. Health Insurance Plan
For all applicants, employees or eligible family members:
39. Is there any other medical or mental health condition not covered in questions 1 - 38?
III. LIST OF CURRENT MEDICATIONS (Prescription, over the counter, and vitamins/supplements with dosage and frequency) Drug Or Other Allergies
IV. HOSPITALIZATIONS/OPERATIONS/MEDICAL EVACUATIONS (Include all medical and psychiatric illnesses)
Date (mm-dd-yyyy)
Illness or Operation
Name of Hospital
City and State
IIA. Explanations required for "Yes" answers to questions 1-39. Attach additional sheets as needed.
Yes No
Children Only: 34. Has your child been referred for any current or potential special educational services, accommodations,
or modifications (i.e.: IFSP, Early Intervention, IEP, 504 Plan)? Explain:
Women: (provide results if applicable, N/A if not applicable)
35. Date of last PAP test? Results:
36. Date of last Mammogram? Results:
37. Are you pregnant? Est. due date:
Yes No
IN THE PAST SEVEN (7) YEARS (for questions 29-33)
(parents - please answer for children < 18 years of age)
29. Have you used marijuana, amphetamines, narcotics,
cocaine, or hallucinogenic drugs?
30. Have you been in psychotherapy/counseling or been prescribed
medication for depression, anxiety, mood or stress?
31. Have you felt unusually depressed, sad, blue, or had frequent
crying spells which lasted more than two weeks at a time?
32. Have you had frequent or recurrent episodes of:
difficulty in relaxing or calming down, panicky feelings,
irritability, anger, feeling hyper, or nervousness?
DS-1843
Page 2 of 4
Name of Examinee
Do you (or your child) have a hisory of:
(parents - please answer for children < 18 years of age)
Yes
1. Frequent/severe headaches or migraines?
2. Fainting, dizzy episodes, or syncope?
No
3. Stroke, TIA or head injury?
4. Epilepsy, seizures or other neurologic disorders?
5. Eye or vision problems?
6. Ear, nose, throat problems; hearing loss, hoarseness?
7. Allergies or history of anaphylactic reaction?
8. Shortness of breath, asthma, or COPD?
9. History of abnormal chest x-ray?
10. History of positive TB skin test, IGRA, or tuberculosis?
11. Aneurysm, blood clot or pulmonary embolism?
12. High blood pressure?
13. Murmurs, palpitations, or other heart problems?
14. Are you a former or current smoker?
15. Stomach, esophageal, or other intestinal problems?
16. Jaundice, hepatitis, or other liver disease?
17. Intestinal, rectal problems or hernia?
18. Urinary or kidney problems, blood in urine?
19. Diabetes, thyroid, or other endocrine disorders?
20. Joint or back pain/injury?
DOB
II. MEDICAL HISTORY
ANSWER THE FOLLOWING QUESTIONS: ALL YES ANSWERS MUST HAVE A WRITTEN EXPLANATION WITH DATE OF OCCURENCE IN BOX IIA.
28. Have you consumed at any one time in the past year,
more than 5 alcohol drinks for males or 4 drinks for
females? Explain.
Yes No
21. Rheumatologic disorder?
Yes
22. Anemia?
No
23. Blood transfusion?
24. Malaria, tropical or other infectious disease?
25. Any skin or nail disorder?
26. Cancer of any type?
27. Any thickening or lump in breast, testicle?
X
Date (mm-dd-yyyy)
V. SIGNATURE OF EXAMINEE OR PARENT OF CHILD <18 Y/O (I certify I have read and understand the above statement.)
Any knowing and willful omission, falsification, or fraudulent statement regarding material medical information may constitute a criminal
offense under 18 U.S.C. § 1001, and individuals committing such an offense may be subject to criminal prosecution. Employees of the
United States Government also may be subject to disciplinary action, up to and including separation, for any knowing and willing omission
or falsification or fraudulent statement of material information.
33. Have you experienced any emotional or physical
symptoms related to a past trauma?
Yes No
Colon Cancer Screening: (Submit results)
38. History of abnormal colon cancer screening?
Test (colonoscopy/sigmoidoscopy/guiacFOBT):
Results:
Yes No
Date
Notes
(Describe every abnormality in detail.
Include pertinent item number before each comment.)
IX. Clinical Evaluation
Check each item as indicated.
Check "NE" if not evaluated.
Normal Abnormal NE
1. General/Constitution
1. Height 4. Pulse 5. Blood Pressure (sitting)
If above 140/85 repeat 3 times and record.
2. Weight
lbs. or
kgs
in. or
cm.
VIII: Clinical Evaluation
2. Mental / Affect / Mood / (Development-children)
3. Skin
4. Eye
5. Ears/Nose/Throat
6. Neck/Thyroid
7. Lungs/Thorax
8. Breasts
9. Cardiovascular
(Record murmurs/abnormalities)
10. Abdomen
11. Male Genitalia
12. Anus/Rectum/Prostate (if indicated)
13. Musculoskeletal / Spine / Extremities
(Note limitations)
14. Lymph Nodes
15. Neurologic
16. Female Gynecologic (if indicated)
3. BMI
VII: Medical Examiner comments on significant patient medical history and items checked "yes" on page 2/section II. Use additional pages
if needed.
DS-1843
Page 3 of 4
Name of Examinee DOB
VI. INSTRUCTIONS FOR COMPLETION AND SUMBISSION OF FORM DS-1843
NOTICE: This history and physical are used to make a medical clearance decision based on an individual's anticipated medical requirements while
living or traveling abroad. This exam does not meet the requirements of an age appropriate wellness exam.
MEDICAL EXAMINER
• Medical Examiner must comment on positive history (pg. 2), abnormal physical findings (pg. 3), and provide follow-up recommendations (pg. 4).
• Medical Examiner must sign on page 4.
EXAMINEE / SPONSOR / PARENT
• All fields on page 1 and 2 must be filled out. Examinee or parent/employee sponsor must sign on page 2.
• Submit copies of all laboratory tests and additional medical reports with DS-1843.
• All Lab tests and medical reports must be in English, and identified with full name and date of birth of examinee.
• Keep originals as a permanent record. Do NOT submit by U.S. Mail or by courier service (e.g. FedEx or DHL).
Submit the DS-1843 and other documentation via email in PDF format to MEDMR@state.gov (preferred), or by fax to the Medical Records Department
at 202-647-0292. If you wish to confirm that your exam forms were received, email MEDMR@state.gov.
DS-1843 Page 4 of 4
Name of Examinee DOB
IX. LABORATORY ANALYSIS COPIES OF LABORATORY REPORTS MUST BE ATTACHED
1. Required Labs (Must attach)
A. Hematology (must include: Hematocrit, Hemoglobin, White Blood Cell Count, and Platelets)
B. Chemistry (must include: Fasting Blood Sugar, Creatinine, and ALT. Hemoglobin A1c if indicated)
C. Serology (must include: HEP B Surface Antigen, HEP C Antibody, RPR/VDRL, and HIV I/II Antibody)
D. Lipid Profile (only if > 50 years of age: Total Cholesterol, LDL, HDL, and Triglycerides)
4. ECG (50 years or older, earlier if indicated) -
SUBMIT TRACING
Results:
Date:
OPTIONAL TESTS: The following tests are not required for a medical clearance determination. The expense of performing these exams is not
routinely authorized. The tests may be performed at the clinical discretion of the examiner with patient consent. If performed or previous results are
available, the results may be used by the Department of State in a medical clearance determination and future clinical care of individuals covered
under the Department's Medical Program.
X. Assessment or Problem List XI. Recommendation for Treatment / Further Study / Consultation or
Follow - Up
5. Blood Type ( if not previously documented)
Type: ABO
(weak D):
6. G6PD (If not previously documented) for malarial prophylaxis
Results:
Date:
7. PAP/Cervical Cytology
Results:
Date:
(Rh) Dµ:
8. Mammogram
Date:
9. Colon Cancer Screen
Results:
Date:
Test (colonoscopy/sigmoidoscopy/guiac FOBT/other):
Results:
ALL TESTS ARE REQUIRED UNLESS OTHERWISE SPECIFIED. TEST RESULTS FROM PREVIOUS 12 MONTHS ARE ACCEPTABLE.
LABORATORY REPORTS MUST BE IN ENGLISH. ATTACH LABS TO THIS FORM.
2. Tuberculin Skin Test : REQUIRED (unless previously positive)
For baseline status as individual who will live overseas in an endemic TB area.
IGRA Results: Date:
Interferon Gamma Release Array: (may substitute for TST if > 5 y/o or
In those with previous BCG)
Previous active tuberculosis
Previous positive TST or IGRA
Previous LTBI treatment
Hx of BcG vaccine
NoYes
NoYes
NoYes
NoYes
Date:
Date:
Date:
Date:
TST Results:
mm of induration Date:
3. Chest X Ray (PA and lateral) - Required only if TST >
10mm, positive IGRA or clinically indicated.
Results:
Date:
Signature of Examiner
Typed Name of Examiner Date (mm-dd-yyyy)
Telephone NumberAddress
NOTICE: This form is not complete until all laboratory tests and results from section IX are attached and included with this DS-1843 form.
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Completed 9 June 2022

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