Instructions: Please answer each of the following questions. Be sure to attach copies of any medical reports that can
help clarify a medical condition(s). Failure to provide Medical Clearances with pertinent information will delay processing
of the medical clearance decision and post assignment approval. Scan and e-mail the completed 2-page form to
MEDMR@state.gov or fax to 202-647-0292.
Yes / No
1. Conditions that prevent the wearing of personal
protective equipment, including protective mask, ballistic
helmet, body armor, and chemical/biological protective
garments, regardless of the nature of the condition that
causes the inability?
2. Conditions that prohibit required
immunizations (other than smallpox & anthrax per current
guidance) or medications (such as anti-malarials, chemical
and biological antidotes, and other chemoprophylactic
3. Any chronic medical condition that requires
frequent clinical visits (more than quarterly) or ancillary
tests (more than twice/year), that fails to respond to
adequate conservative treatment, necessitates significant
limitation of physical activity, or constitutes increased risk
of illness, injury, or infection?
4. Any unresolved acute illness or injury that
would impair one's duty performance during the duration of
5. Asthma that has a Forced Expiratory Volume-1
< 50% of predicted despite appropriate therapy, that has
required hospitalization in the past 12 months, or that
requires daily systemic (not inhaled) steroids?
6. Seizure disorder, either within the last year or
currently on anticonvulsant medication for prior seizure
7. Diabetes mellitus?
8. History of heat stroke?
9. Meniere's disease or other vertiginous/motion
10. Renalithiasis (Kidney stones), recurrent or
11. Obstructive sleep apnea (OSA)?
12. History of clinically diagnosed as having
Traumatic Brain Injury (TBI) or concussion?
13. Symptomatic coronary artery disease?
14. Chronic cough or coughing up blood?
15. Myocardial infarction within past two years?
16. Coronary artery bypass graft, coronary artery
angioplasty, carotid endarterectomy, other arterial stenting,
or aneurysm repair within 2 years?
17. Cardiac dysrhythmias or arrhythmias, either
symptomatic or requiring medication, electrophysiologic
control, or automatic implantable cardiac defibrillator?
Yes / No
18. Hypertension not controlled with medication
or that requires frequent monitoring?
19. Heart failure or history of heart failure?
20. Morbid obesity (BMI > 40) in accordance with
National Heart Lung and Blood Institute guidelines?
21. Active or chronic blood-borne diseases
(Hepatitis B, Hepatitis C, HIV)?
22. Active tuberculosis?
23. Untreated Latent tuberculosis, or is currently
24. Vision loss?
25. Refractive eye surgery in last year?
26. Currently using ophthalmic steroid drops?
27. Photorefractive keratectomy (PRK) or laser
epithelial keratomileusis (LASiK) within the past 6 months?
28. Hearing loss?
29. On-going dental or orthodontic work?
30. On-going cancer therapy?
31. Precancerous lesions that have not been
32. Any medical condition that requires surgery
(e.g., unrepaired hernia) or for which surgery has been
performed and the patient requires ongoing treatment,
rehabilitation or additional surgery to remove devices (e.g.,
external fixator placement)?
33. Surgery (open or laparoscopic) within past 6
34. Psychotic and Bipolar Disorders?
35. Clinical psychiatric disorders with residual
symptoms, or medication side effects?
36. History of the following: psychiatric
hospitalization; suicide attempt; substance (medication,
illicit drug, alcohol, inhalant, etc.) abuse or treatment for
such abuse; PTSD or/TBI?
37. Medications - Blood modifiers?
38. Medications - Antineoplastics (oncologic or
39. Medications – Immunosuppressants?
40. Medications - Biologic Response Modifiers
41. Medications – Psychiatric or sleeping aides?
42. Medications – Anticonvulsants?
43. Medications – Pain medications, Opioids,
opioid combination drugs?
DS-6570 Page 2 of 2
Patient Printed Name
Public reporting burden for this collection of information is estimated to average 30 minutes 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 recommendations for reducing it, please send them to Office of Quality Improvement, U.S. Department of
State, M/MED/QI, SA-01, Washington DC 20522-0102; firstname.lastname@example.org.
Patient Signature Date
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