Fillable MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICEFOR INDIVIDUALS AGE 12 AND OLDER Form DS-1843

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MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICEFOR INDIVIDUALS AGE 12 AND OLDER Form DS-1843

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MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE
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 on this form will be used to make appropriate medical clearance decisions.
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
Domestic Partner
Applicant
Dependent Child
State
Employee
8. Foreign Service Agency
Foreign Commercial Service
STATE
Foreign Agricultural Service USAID
Board of Broadcasting Governors
9. Health Insurance Plan
13. Post of Assignment and Estimated Dates of Arrival / Departure
a. Proposed Post
b. Present Post
c. Last 3 Posts
EDD
EDA
(mm-dd-yyyy)
(mm-dd-yyyy)
11. Purpose of Exam
Pre-Employment Exam
In-Service Exam
Separation Exam
14. Mailing Address
(Where You can be reached for the Next 90 days)
12. Telephone Number of examinee or parent of child < 18 y/o
(Where You can be reached for the Next 90 days)
10. E-mail Address of examinee or parent of child < 18 y/o
(Where You can be Reached for the Next 90 days)
Office of Medical Services, Room L101, SA-1, Washington, DC 20522-0102
*OMB APPROVAL NO. 1405-0068
EXPIRATION DATE: 08-31-2020
ESTIMATED BURDEN: 1 HOUR
U.S. Department of State
DS-1843
07-2017
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.
For all applicants, employees or eligible family members:
39. Is there any other medical or mental health condition not covered in questions 1 - 38? Explain:
III. LIST OF CURRENT MEDICATIONS (Include prescription, over the counter, vitamins, and herbs) 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:
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 or dizzy episodes?
No
3. Stroke, TIA or head injury?
4. Epilepsy, seizures or other neurologic disorders?
5. Chronic 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 or tuberculosis?
11. Aneurysm, blood clot or pulmonary embolism?
12. High blood pressure?
13. Heart problems, murmur or palpitations?
14. Have you smoked any cigarettes in the last month?
15. Stomach, esophageal, intestinal problems?
16. Jaundice or hepatitis (type)?
17. Intestinal, rectal problems or hernia?
18. Urinary or kidney problems, blood in urine?
19. Diabetes or thyroid disorder?
20. Joint or back pain/injury?
DOB
II. MEDICAL HISTORY
PLEASE ANSWER THE FOLLOWING QUESTIONS: For YES answers, provide a brief explanation, attach additional sheets, if needed.
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.
21. Rheumatologic disorder?
Yes
22. Anemia?
No
23. Blood transfusion?
24. Malaria or other tropical disease?
25. Any skin or nail disorder?
26. Cancer of any type?
27. Any thickening or lump in breast, testicle?
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
Men/Women: Colon Cancer Screening:
(provide results if applicable, N/A if not applicable)
38. Date of last colon cancer screening, if applicable:
Test (colonoscopy/sigmoidoscopy/guiacFOBT):
Results:
Yes No
dd mmm yyyy
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Notes
(Describe every abnormality in detail.
Include pertinent item number before each comment.)
VII. 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.
VII: 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
VI: 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
V. INSTRUCTIONS FOR COMPLETION AND SUMBISSION OF FORM DS-1843
MEDICAL EXAMINER
• Medical Examiner must comment on positive history on page 2. Medical Examiner must comment on physical findings and provide
recommendations for treatment/further study/consultations of medical & mental health problems.
• 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). The preferred method to submit
the DS - 1843 (and supporting documentation) is to scan and email in PDF format to: MEDMR@state.gov. If it is not possible to scan, please fax to
Medical Records department FAX: 703-875-4850. If you wish to confirm that your exam forms were received, please email MEDMR@state.gov.
dd mmm yyyy
DS-1843 Page 4 of 4
Name of Examinee DOB
IX. LABORATORY ANALYSIS: All tests are required unless otherwise specified. Test results from previous 12 months are acceptable.
COPIES OF LABORATORY REPORTS MUST BE SUBMITTED FOR REVIEW AND MUST BE IN ENGLISH
1. Hematology
Hematocrit %
or
Hemoglobin gms%
WBC /cmm
Platelets
2. Chemistry
Fasting Blood Sugar
HgA1C (if indicated)
Creatinine
ALT
3. Serology
HEP B Surface Antigen
HEP C Antibody
RPR/VDRL
HIV I/II Antibody
4. Urinalysis (only if indicated)
WBC
RBC
Protein
Other
5. Tuberculin Skin Test: Required for ages 1 and over (unless previously positive) 6. Chest X Ray (PA and lateral) - submit report
Pre-Employment : Required for applicant/family member > 18
years old
In-service Exam : Required for those with > 10 mm TST newly
identified or positive IGRA OR when clinically indicated
Results: mm of induration Date:
Interferon Gamma Release Assay: (may substitute for TST if > 5 y/o or
In those with previous BCG)
Results:
Date:
If no TB screening performed, explain why:
Previous active tuberculosis
Previous positive TST or IGRA
Previous LTBI treatment
Hx of BcG vaccine
Other:
NoYes
NoYes
NoYes
NoYes
Date:
Date:
Date:
Date:
Results: Date:
7. ECG (50 years or older, earlier if indicated) - submit tracing
Results:
Date:
OPTIONAL TESTS: The following tests may be performed at the discretion of the Examiner, with patient consent. They are not required for a medical
clearance determination. If performed, results may be used in the provision of care to individuals covered under the Department of State Medical
Program. *Cancer screening tests should be performed as indicated by age, medical history/risk and current cancer screening guidelines
X. Assessment or Problem List XI. Recommendation for Treatment / Further Study / Consultation or
Follow - Up
8. Blood Type ( if not previously documented)
Type: ABO
(weak D):
9. G6PD (If not previously documented) for malarial prophylaxis
Results:
Date:
10. PAP/Cervical Cytology
Results:
Date:
(Rh) Dµ:
11. Mammogram
Date:
12. Colon Cancer Screen
Results:
Date:
Test (colonoscopy/sigmoidoscopy/guiac FOBT/other):
Results:
Signature of Examiner
Typed Name of Examiner Date (mm-dd-yyyy)
Telephone NumberExamining Facility
Address
dd mmm yyyy
dd mmm yyyy
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dd mmm yyyy
dd mmm yyyy
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dd mmm yyyy
dd mmm yyyy
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MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICEFOR INDIVIDUALS AGE 12 AND OLDER Form DS-1843

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Completed 13 May 2019

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