DS-1843 Medical History and Examination for Individuals Age 12 a

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

*OMB APPROVAL NO. 1405-0068
EXPIRATION DATE: XX-XX-20XX
ESTIMATED BURDEN: 1 HOUR

MEDICAL HISTORY AND EXAMINATION
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 from this form will assist in making a medical clearance decision for individuals eligible to participate in the
Department of State Medical Program while assigned abroad. (16 FAM 100 - 200)
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
DATE OF EXAM (mm-dd-yyyy)

I. DEMOGRAPHIC INFORMATION
TO BE FILLED OUT BY EXAMINEE (OR PARENT)
1. Name of Examinee (Last, First, MI)

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

2. If Eligible Family Member, Name of Employee/Applicant

4. MED ID (if available)

5. Sex
Male

6. Place of Birth
Country

State

City

7. Status
Applicant
Dependent Child

Female
New Family Member

Employee

(Spouse, Newborn, Adoption)

Spouse

8. Agency of Employee/Applicant/Sponsor
STATE

USAID

FCS

FAS

Non-Foreign Service Agency
9. Health Insurance Plan

U.S. Agency for Global Media

DoD Contractor

Contracting Company
10. Purpose of Exam
Pre-Employment Exam
In-Service Exam
Separation Exam

12. E-mail Address of examinee or parent of child < 18 y/o
(Where You can be Reached for the Next 90 days)

DoD Civilian

REA-WAE

11. Employment Status
Civil Service

LES

Contractor

LNA

PSC Contractor

Fellow

FS Officer

Other

FS Specialist

14. Employment Status
Primary:
Alternate:

TDY (Regional hub or CONUS based)
Iraq - List Post
Afghanistan

13. Telephone Number of examinee or parent of child < 18 y/o
(Where You can be Reached for the Next 90 days)

Other ESCAPE Post(s) If yes, list
15. Post of Assignment and Estimated Dates of Arrival / Departure

Primary:

a. Proposed Post

EDA
(mm-dd-yyyy)

Alternate:
b. Present Post

EDD
(mm-dd-yyyy)

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.

DS-1843
06-2020

Page 1 of 4

Name of Examinee

DOB

II. MEDICAL HISTORY
ANSWER THE FOLLOWING QUESTIONS: ALL YES ANSWERS MUST HAVE A WRITTEN EXPLANATION WITH DATE OF OCCURENCE IN BOX IIA.

Do you (or your child) have a hisory of:

Yes

No

(parents - please answer for children < 18 years of age)
Yes No

21. Rheumatologic disorder?
22. Anemia?

1. Frequent/severe headaches or migraines?

23. Blood transfusion?

2. Fainting, dizzy episodes, or syncope?

24. Malaria, tropical or other infectious disease?

3. Stroke, TIA or head injury?

25. Any skin or nail disorder?

4. Epilepsy, seizures or other neurologic disorders?

26. Cancer of any type?

5. Eye or vision problems?

27. Any thickening or lump in breast, testicle?

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, IGRA, or tuberculosis?
11. Aneurysm, blood clot or pulmonary embolism?
12. High blood pressure?
13. Murmurs, palpitations, or other heart problems?
14. Are you a former or current smoker?

Yes

No

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.
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?

15. Stomach, esophageal, or other intestinal problems?

31. Have you felt unusually depressed, sad, blue, or had frequent
crying spells which lasted more than two weeks at a time?

16. Jaundice, hepatitis, or other liver disease?

32. Have you had frequent or recurrent episodes of:
difficulty in relaxing or calming down, panicky feelings,
irritability, anger, feeling hyper, or nervousness?
33. Have you experienced any emotional or physical
symptoms related to a past trauma?

17. Intestinal, rectal problems or hernia?
18. Urinary or kidney problems, blood in urine?
19. Diabetes, thyroid, or other endocrine disorders?
20. Joint or back pain/injury?

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)

Colon Cancer Screening: (Submit results)
38. History of abnormal colon cancer screening?

35. Date of last PAP test?
36. Date of last Mammogram?
37. Are you pregnant?
Yes

Results:
Results:
No Est. due date:

Yes

No
Date

Test (colonoscopy/sigmoidoscopy/guiacFOBT):
Results:

For all applicants, employees or eligible family members:
39. Is there any other medical or mental health condition not covered in questions 1 - 38?

Yes

No

IIA. Explanations required for "Yes" answers to questions 1-39. Attach additional sheets as needed.

III. LIST OF CURRENT MEDICATIONS (Prescription, over the counter, and vitamins/supplements with dosage and frequency)

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

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.
V. SIGNATURE OF EXAMINEE OR PARENT OF CHILD <18 Y/O (I certify I have read and understand the above statement.)

X
DS-1843

Date (mm-dd-yyyy)

Page 2 of 4

Name of Examinee

DOB

VI. INSTRUCTIONS FOR COMPLETION AND SUMBISSION OF FORM DS-1843
NOTICE: This history and physical are used to make a medical clearance decision based on an individual's anticipated medical requirements while
living or traveling abroad. This exam does not meet the requirements of an age appropriate wellness exam.
MEDICAL EXAMINER
• Medical Examiner must comment on positive history (pg. 2), abnormal physical findings (pg. 3), and provide follow-up recommendations (pg. 4).
• 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).
Submit the DS-1843 and other documentation via email in PDF format to MEDMR@state.gov (preferred), or by fax to the Medical Records Department
at 202-647-0292. If you wish to confirm that your exam forms were received, email MEDMR@state.gov.
VII: Medical Examiner comments on significant patient medical history and items checked "yes" on page 2/section II. Use additional pages
if needed.

VIII: Clinical Evaluation
1. Height

2. Weight

3. BMI

in. or

lbs. or

cm.

kgs

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

4. Pulse

Normal Abnormal

5. Blood Pressure (sitting)
If above 140/85 repeat 3 times and record.

NE

Notes
(Describe every abnormality in detail.
Include pertinent item number before each comment.)

1. General/Constitution
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)
DS-1843

Page 3 of 4

Name of Examinee

DOB

IX. LABORATORY ANALYSIS
1. Required Labs (Must attach)

COPIES OF LABORATORY REPORTS MUST BE ATTACHED

A. Hematology (must include: Hematocrit, Hemoglobin, White Blood Cell Count, and Platelets)
B. Chemistry (must include: Fasting Blood Sugar, Creatinine, and ALT. Hemoglobin A1c if indicated)
C. Serology (must include: HEP B Surface Antigen, HEP C Antibody, RPR/VDRL, and HIV I/II Antibody)
D. Lipid Profile (only if > 50 years of age: Total Cholesterol, LDL, HDL, and Triglycerides)
ALL TESTS ARE REQUIRED UNLESS OTHERWISE SPECIFIED. TEST RESULTS FROM PREVIOUS 12 MONTHS ARE ACCEPTABLE.
LABORATORY REPORTS MUST BE IN ENGLISH. ATTACH LABS TO THIS FORM.
2. Tuberculin Skin Test : REQUIRED (unless previously positive)
For baseline status as individual who will live overseas in an endemic TB area.
TST Results:
IGRA Results:

mm of induration

OR

3. Chest X Ray (PA and lateral) - Required only if TST >
10mm, positive IGRA or clinically indicated.
Results:

Date:

Date:

Date:

Interferon Gamma Release Array: (may substitute for TST if > 5 y/o or
In those with previous BCG)
Previous active tuberculosis

Yes

No

Date:

Previous positive TST or IGRA

Yes

No

Date:

Previous LTBI treatment

Yes

No

Date:

Hx of BcG vaccine

Yes

No

Date:

4. ECG (50 years or older, earlier if indicated) SUBMIT TRACING
Results:
Date:

OPTIONAL TESTS: The following tests are not required for a medical clearance determination. The expense of performing these exams is not
routinely authorized. The tests may be performed at the clinical discretion of the examiner with patient consent. If performed or previous results are
available, the results may be used by the Department of State in a medical clearance determination and future clinical care of individuals covered
under the Department's Medical Program.
5. Blood Type ( if not previously documented)

Type: ABO

(Rh) Dµ:

(weak D):

6. G6PD (If not previously documented) for malarial prophylaxis

Results:

Date:

7. PAP/Cervical Cytology

Results:

Date:

8. Mammogram

Results:

Date:

Results:

Date:

9. Colon Cancer Screen
Test (colonoscopy/sigmoidoscopy/guiac FOBT/other):
X. Assessment or Problem List

XI. Recommendation for Treatment / Further Study / Consultation or
Follow - Up

NOTICE: This form is not complete until all laboratory tests and results from section IX are attached and included with this DS-1843 form.
Typed Name of Examiner

Signature of Examiner

Address

Telephone Number

DS-1843

Date (mm-dd-yyyy)

Page 4 of 4