DS-3026 Medical History and Physical Examination Worksheet

			Name (Last, First, MI.)						Exam Date (mm-dd-yyyy)
			Birth Date (mm-dd-yyyy)	Passport Number				Alien (Case) Number
1. Past Medical History
No	Yes				No	Yes
		General Illness or injury requiring hospitalization (including psychiatric) Cardiology Hypertension Congestive heart failure or coronary artery disease Arrhythmia Rheumatic heart disease Congenital heart disease Pulmonology Tobacco use: Current Former Asthma Chronic obstructive pulmonary disease Tuberculosis history: Diagnosed (mm-yyyy) Treated (mm-yyyy) Fever Cough Night sweats Weight loss Psychiatry Major impairment in learning, intelligence, self-care, memory, or communication Major mental disorder (including bipolar disorder, major depression, mental retardation, post-traumatic stress disorder, schizoaffective disorder, schizophrenia) Use of drugs other than those required for medical reasons Addiction (dependence) or abuse of specific substances or drugs on the CSA Other substance related disorders (including alcohol abuse or dependence) Ever caused serious injury to others, caused major property damage or had trouble with the law because of medical condition, mental disorder, or influence of alcohol or drugs Ever had thoughts of harming yourself Ever acted on those thoughts Ever had thoughts of harming others Ever acted on those thoughts Neurology History of stroke Seizure disorder Applicant appears to be providing unreliable or false information, specify in remarks					Obstetrics and Sexually Transmitted Diseases Pregnancy, current Estimated delivery date (mm-dd-yyyy) Pregnancy, birth dates (mm-dd-yyyy) Previous treatment for sexually transmitted diseases, specify date (mm-yyyy) and treatment: Chancroid Gonorrhea Granuloma inguinale Lymphogranuloma venereum Syphilis Endocrinology Diabetes mellitus Thyroid disease Hematologic/Lymphatic Anemia Sickle Cell Disease Thalassemia major Other hemoglobinopathy Other HIV: if previously tested, mm-yyyy of test Wears glasses or contact lenses Malignancy, specify: Chronic renal disease Chronic liver disease (including hepatitis) Hansen’s Disease: Diagnosed (mm-yyyy) Treated (mm-yyyy) Other medical conditions requiring treatment, specify: Disabilities (including loss of arms or legs), specify:
2. Current Medications (List all current medications)					3. Previous Surgeries (List all previous surgeries)

Photo

OMB No. 1405-0113

EXPIRATION DATE: xx/xx/xxxx

ESTIMATED BURDEN: 30 minutes

(See Page 2 – Back of Form)

U.S. Department of State

MEDICAL HISTORY AND

PHYSICAL EXAMINATION WORKSHEET

_{For Use with DS-2054}

_{4. Vital Signs and Vision}

_{Height cm}

_{Weight kg}

_{BMI kg/m2}

_{BP /}

_{Pulse / min}

_{Temperature ○C}

_Respiratory

_{Rate / min}

_{Visual acuity at 20 feet:}

_{Uncorrected L 20/ R 20/}

_{Corrected L 20/ R 20/}

_{5. Physical Examination (include all findings and give details in Remarks)}

N, normal; A, abnormal

_N

_A

_N

_A

General appearance

^{Nutritional status (including acute wasting and or chronic stunting malnutrition)}

_{Hearing and ears}

_Eyes

_{Nose, mouth, and throat (include detail)}

_{Heart (S1, S2, murmur, rub)}

_Lungs

_{Abdomen (including liver, spleen)}

_{Genitalia (including infection(s))}

Inguinal region (including adenopathy)

Musculoskeletal system (including gait)

Extremities (including pulses, edema)

Skin (including hypopigmentation or anesthesia consistent with Hansen’s Disease, evidence of self-inflicted injury or injections)

Hematologic (including signs of anemia such as pallor, koilonychia)

Lymph nodes

Nervous system (including nerve enlargement)

Mental status (including mood, intelligence, perception, thought processes, and behavior during examination)

_{6. Mental Health Specialist}

_{Referral made to mental health specialist. If so, attach report.}

_{7. Syphilis Laboratory Results and Treatment}

_{Laboratory testing not done}

		Test Name		Date specimen obtained (mm-dd-yyyy)			Positive	Negative	Initial Titer
Screening
Confirmatory
Treated Yes No	If treated, therapy: Benzathine penicillin, 2.4 MU IM Other (therapy, dose):						Date(s) treatment given (mm-dd-yyyy)
	Treated by panel physician:				Yes	No
	Stage of syphilis (mark one): Primary Secondary Early latent Late latent or latent of unknown duration		Tertiary Neurosyphilis Congenital

_{8. Diagnosis and Treatment of Other Sexually Transmitted Infections}

_{Infection: Chancroid Gonorrhea Granuloma inguinale Lymphogranuloma venereum}

Diagnosed _{by panel physician: Yes No Treated by panel physician: Yes No}

Drug	Dosage	Start Date (mm-dd-yyyy)	End Date (mm-dd-yyyy)

_{9. Diagnosis and Treatment for Hansen’s Disease}

_{Type of Hansen’s Disease}

_{Multibacillary}

_{Paucibacillary}

_{Treated by panel physician}

_Yes

_No

_Treatment

_Partial

_Completed

Drug	Dosage	Start Date (mm-dd-yyyy)	End Date (mm-dd-yyyy)

_{If not treated by panel physician, was referral made by panel physician to another provider for treatment:}

_{Yes. Provide facility name:}

_No

_Diagnosis

_{Initial diagnosis made by panel physician}

_{Initial diagnosis made by non-panel physician before medical evaluation by panel physician}

_{If so, year of diagnosis:}

10. Remarks

PAPERWORK REDUCTION ACT STATEMENT

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: PRA_BurdenComments@state.gov

CONFIDENTIALITY STATEMENT

AUTHORITIES The information asked for on this form is requested pursuant to Section 212(a) and 221(d) and as required by Section 222 of the Immigration and Nationality Act. Section 222(f) provides that the records of the Department of States and of diplomatic and consular offices of the United States pertaining to the issuance and refusal of visas or permits to enter the United States shall be considered confidential and shall be used only for the formulation, amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies of such records may, in the discretion of the Secretary of State, be made available to a court provided the court certifies that the information contained in such records is needed in a case pending before the court.

PURPOSE The U.S. Department of State uses the facts you provide on this form primarily to determine your classification and eligibility for a U.S. immigrant visa. Individuals who fail to submit this form or who do not provide all the requested information may be denied a U.S. immigrant visa. Although furnishing this information is voluntary, failure to provide this information may delay or prevent the processing of your case.

ROUTINE USES If you are issued an immigrant visa and are subsequently admitted to the United States as an immigrant, the Department of Homeland Security will use the information on this form to issue you a Permanent Resident Card, and, if you so indicate, the Social Security Administration will use the information to issue a social security number. The information provided may also be released to federal agencies for law enforcement, counterterrorism and homeland security purposes; to Congress and courts within their sphere of jurisdiction; and to other federal agencies who may need the information to administer or enforce U.S. laws. More information on the Routine Uses for this collection can be found in the System of Records Notice State-24, Medical Records.

DRAFT6

DS-3026 Page 3 of 3

08-2011