Form DS-1622 MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE - Ch

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: 04-30-2012
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. 4084, 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. The information requested is voluntary however 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

5. Agency of Employee/Applicant/Sponsor
Male

State

Female

Foreign Commercial
Service

USAID

6. eMED Number if known (Employee/Applicant/Sponsor)
Board of Broadcasting
Governors

Foreign Agricultural Service
7. Place of Birth

8. Post of Assignment and Dates of Departure/Arrival
a. Proposed Post

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

EDA

(mm-dd-yyyy)

b. Present Post
EDD
Telephone Number
(where you can be
reached for the next
90 days)
E-mail Address
(where you can be
reached for the
next 90 days)

(mm-dd-yyyy)

c. Last 3 Posts

10. Name of Your Health Insurance Plan

11. Purpose of Examination
a. In-Service
12. Is Child Adopted?
Yes

b. Separation

c. 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. The following asks questions about family medical history.
Providing this information is strictly voluntary and will only be used for diagnosis and treatment, and only by providers in MED. Medical clearance
decisions do not take into consideration family medical history, but only manifested medical conditions. Therefore examinee is not required to answer.
a. Father
b. Mother
c. Grandmother(s)
d. Grandfather(s)
e. Sister(s)
f. Brother(s)
g. Aunt(s)
h. Uncle(s)
13. As part of this examination, you may be asked for Family Medical History. Providing this information is strictly voluntary and will only be used for
diagnosis and treatment, and only by medical providers in MED. Medical clearance decisions do not take into account Family Medical History, but
only manifest diseases and medical conditions."

Signature of Parent

DS-1622
xx-2011

Date (mm-dd-yyyy)

*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/GIS/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?
3. Any neurological disorder?
4. Chronic eye trouble or vision problems?
Date of last eye exam (mm-dd-yyyy)
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?

No
13. Rheumatologic problems; tendon, joint or
back pain/injury; bone deformity or fracture?
14. Malaria or other tropical disease?
15. Any hair, nail or skin problems or disorders?
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
Name of Hospital

Date (mm-dd-yyyy)

Drug Or Other Allergies

City and State

Is there 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
1. Height

Name Of Examinee
2. Weight

3. Pulse (must be recorded)

in. or

lb. or

cm.

kg.

percentile

percentile
6. Head Circumference
(18 months and under)

5. Distant Vision (age 5 and over)
Right 20/

Corrected 20/

Left 20/

Corrected 20/

4. Blood Pressure
(age 5 and Over)

in. or
cm.

7. Development Appropriate for Age
Yes
No
Attach development screen if indicated under age 4
8. Immunizations Reviewed
Yes
No
Immunizations current?

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

Normal Abnormal

NE

Yes
No
Notes
(Describe every abnormality in detail.
Include 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)
6. Pre-employment Only
recommended for all ages 1 and over, including
(recommended for ages 9
(or if previously not done)
those with previous BCG)
mo. up to 6 years)
a. Blood Type
Date (mm-dd-yyyy)
%
Hematocrit
ABO
Results
mm of induration
4. Chest X-RAY (for new TB
2. Urinalysis (preemployment
skin test convertors, or when
age 1 and over, separation and
indicated).
when indicated).
Previous BCG
Yes
No
(Rh) D
Specific
u
Previous Positive
Yes
No
Gravity
(weak) D
Albumin

Date (mm-dd-yyyy)

Previous Rx completed

Yes

Sugar

Casts

Normal

Date completed (mm-dd-yyyy)

WBC
RBC

No b. G6PD

Results

New Converter (XRay required)

Yes

No

Deficient

Treatment:

Other
DS-1622

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IX. Assessment Or Problem List

Name Of Examinee
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:
Parent or sponsor must sign on page 2. Medical provider must sign on page 4.
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 and Private Health Care Providers:
The preferred method to submit the DS-1622 is to scan and send by email to: MEDMR@state.gov.
If it is not possible to scan, then please fax the DS-1622 to Medical Records at Fax: 703-875-4850.
If you wish to confirm that your exam forms were received please email MEDMR@state.gov.

DS-1622

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