DS-1622 Medical History and Examination for Foreign Service For

U.S. Department of State
Office of Medical Services, Room L101, SA-1, Washington, DC 20522-0102

MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE

*OMB APPROVAL NO. 1405-0068
EXPIRATION DATE: xx-xx-xxxx
ESTIMATED BURDEN: 1 HOUR

FOR CHILDREN 11 YEARS AND UNDER
PRIVACY ACT NOTICE: This information is requested pursuant to the Foreign Service Act of 1980, as amended (22 U.S.C. 3084, 3901 and 3984).
The primary purpose for soliciting this information is to make appropriate assignments abroad. Unless otherwise protected by medical privacy
regulations, the information solicited on this form may be made available to appropriate agencies, whether federal, state, local or foreign, for law
enforcement and administration purposes. It may also be disclosed pursuant to court order. Failure to provide this information may result in denial of a
medical clearance and affect your Foreign Service eligibility.
Date (mm-dd-yyyy)

I. To Be Filled Out By Sponsor Or Parent (complete all sections, type or in ink).
1. Name of Examinee (Last, First, MI.)

3. Date of Birth (mm-dd-yyyy)

2. Full Name of Employee/Applicant/Sponsor

4. Sex

5a. Agency of Employee/Applicant/Sponsor
Male

State

Female

6. Social Security Number (Employee/Applicant/Sponsor)

Contractor

Civil Service
Excursion Tour

8. Post of Assignment and Dates of Departure/Arrival
Country

State

City

Other

5b. Type of Employment
Foreign Service

7. Place of Birth

USAID

a. Proposed Post
EDA

9. Mailing Address
(Medical Clearance Abstract will be mailed to listed address)

(mm-dd-yyyy)
b. Present Post
EDD
(mm-dd-yyyy)

Telephone Number
(where you can be
reached for the next
90 days)

c. Last 3 Posts

E-mail Address
(where you can be
reached for the next
90 days)

10. Name of Your Health Insurance Plan

11. Purpose of Examination
12. Is Child Adopted?

a. Pre-Employment
Yes

b. In-Service

c. Separation

d. New Dependent

No

Check and Describe Medical Conditions of Blood Relatives. Include Sickle Cell Disease, Cancer, Alcoholism, Heart Disease, High Cholesterol,
Kidney Disease, High Blood Pressure, Asthma, Mental Health Problem or Learning Disability.
Father
Mother
Grandmother(s)
Grandfather(s)
Sister(s)
Brother(s)
Aunt(s)
Uncle(s)

Clearance Action

DS-1622
xx-xxxx

DO NOT WRITE IN THE SPACE BELOW (FOR USE BY MEDICAL DIVISION ONLY)

*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 recommendations for reducing it, please send them to: A/ISS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC
20522-2202.

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II. Have You Ever Had:
Yes

Name of Examinee

No

Yes
1. Frequent or severe headaches?
2. Dizzy spells, fainting, or seizures?

No
13. Rheumatologic problems; tendon, joint or
back pain/injury; bone deformity or fracture?

3. Any neurological disorder?

14. Malaria or other tropical disease?

4. Chronic eye trouble or vision problems?

15. Any hair, nail or skin problems or disorders?

Date of last eye exam:
5. Tooth or gum problems?
6. Ear, nose, or throat problems, including
hearing difficulties, hoarseness, or allergies?
7. Cough, wheezing, shortness of breath or
asthma?
8. Heart murmur or heart problems?
9. Rheumatic fever?
10. Esophagus, stomach, intestinal, rectal, liver,
or gallbladder problems?
11. A change in urinary habits, urinary tract
infection, bedwetting or stones, blood or
protein in urine?
12. Diabetes; thyroid or other hormonal/
metabolic disease?

16. History of positive TB skin test or clinical tuberculosis/
TB exposure or BCG vaccination?
17. Anemia or blood transfusion?
18. Recent gain or loss of 10 lbs or more?
19. Frequent crying spells, trouble sleeping,
sadness, withdrawal, fears, or worries?
20. Difficulty in relaxing or calming down;
feelings of confusion?
21. Low academic functioning or learning
disability or disorders?
22. Behavioral or discipline problems at home or school?
23. Have you ever been referred to or received
mental health treatment?
24. Other?

III. List Current Medications (Include prescription, over the counter, vitamins, and herbals)

IV. Hospitalizations/Operations/Medical Evacuation (Include all medical and psychiatric illnesses)
Illness or Operation
Date (mm-dd-yyyy)
Name of Hospital

Drug Or Other Allergies

City and State

Anything else you would like to mention about your child's health or well being? Parent should explain "yes" answers to questions 1-24.

Please Recheck All Items for Completeness and Accuracy. DO NOT INDICATE: "Previously Answered"
The intentional omission of any crucial medical information is a criminal offense (Section 1001 of the U.S.C. Title 18). Pre-employment applicants who
intentionally omit information that would make them ineligible for appointment, will be subject to disciplinary action, including separation for cause if
they are hired. Current employees may also be subject to disciplinary action for intentional omission of information.
Signature of Sponsor or Parent (I certify I have read and understand the above statements)

Date (mm-dd-yyyy)

V. To Be Completed By The Examiner (Read Section X Before Proceeding)
Significant History (Note: The Examiner MUST comment on ALL items checked "YES" in Part II).

DS-1622

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VI. To Be Completed By The Examiner

Name Of Examinee

1. Race (check one)
(need for genetic risk factors)

3. Weight

White

2. Height

4. Pulse (must be recorded)

in. or

Black

lb. or
kg.

cm.

Other (specify)

percentile

percentile
7. Head Circumference
(18 months and under)

6. Distant Vision (age 5 and Over)
Right 20/

Corrected 20/

Left 20/

Corrected 20/

in. or

8. Development Appropriate for Age
Yes

No

Attach development screen if indicated under age 4
9. Immunizations Reviewed
Yes
No

cm.

Immunizations current?

VII. Clinical Evaluation
Check each item as indicated. Check "NE" if not evaluated.

5. Blood Pressure
(age 5 and Over)

Normal Abnormal

NE

Yes

No

Notes
(Describe Every Abnormality in Detail.
Pertinent Item Number Before Each Comment)

1. General/Constitution
2. Skin
3. Eyes
4. Ears/Nose/Throat
5. Neck/Thyroid
6. Lungs/Thorax
7. Breasts
8. Cardiovascular
9. Abdomen
10. Male Genitalia
11. Anus/Rectum/Prostate
12. Musculoskeletal
13. Lymphatic
14. Neurological
15. Female Gynecologic
16. Miscellaneous
17. Papanicolaou done

Not done

Reason if not done

18. Attach cytology report.
Additional Comments

VIII. All Of The Following Tests Are Required Unless Otherwise Specified (No LAB required for newborns)
1. Hematology (age 1 and over) 3. Blood Lead Level
5. Tuberculin Test (5TU PPD)
recommended for all ages 1 and over, including
(recommended for ages 9
those with previous BCG)
mo. up to 6 years)
Date (mm-dd-yyyy)
%
Hematocrit
2. Urinalysis (preemployment
age 1 and over, separation and
when indicated).
Specific
Gravity
Albumin
Sugar

4. Chest X-RAY (for new TB
skin test convertors, or when
indicated).

Date (mm-dd-yyyy)

RBC
Casts

Results

a. Blood Type
ABO

Results

mm of induration

Previous BCG

Yes

No

(Rh) D

Previous Positive

Yes

No

(weak) D

Previous Rx completed

Yes

No

New Converter (XRay required) Yes

u

b. G6PD
Normal

Date completed (mm-dd-yyyy)

WBC

6. Pre-employment Only
(or if previously not done)

No

Deficient

Treatment:

Other
DS-1622

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Name Of Examinee
IX. Assessment Or Problem List

Recommendation For Treatment/Further Study

Typed Name of Examiner

Signature

Examining Facility and Telephone Number

Address

Date (mm-dd-yyyy)

X. Instructions to the Examiner
Disposition of Records:
All reports must be in English and identified with the full name and date of birth of the examinee.
Do Not Submit Reports by US Mail.
Do Not Submit Reports by Professional Courier Service (e.g. FedEx or DHL).
Keep originals as a permanent record.
For U.S. Department of State Health Units:
The preferred method to submit the DS-1622 is by way of eForms to Medical Records. If this is not possible, please submit the completed
document by FAX.
For Private Health Care Providers:
Please FAX the completed DS-1622 directly to Medical Records.
Department of State, Medical Records:
FAX: (703) 875-5414 or (703) 875-4850
Please confirm the report was received by sending an e-mail to MedMr@state.gov
DS-1622

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