DS-7794 Panel Physician Report on Medical Examination and Vaccin

Pre exam: Health case details
Panel Physician Report on Medical Examination and Vaccination Record
OMB Control Number
Form Number
Expiration Date
Estimated Burden

Client personal details

DS-7794
09/30/2020
60 minutes

Client identity details

Family
name
Surnames

Given name(s)
names

Sex
Gender

Date
of birth
Birth date

Country
of (Country)
Birth
Birthplace

City of Birth
Birthplace
(City)

*

Prior Country of Residence

*

Select an Option

Country of Nationality

*

Select an Option

Document
type presented
Identity
document

Original Passport

Number
Document
/ IDNumber

Issuing Country

Date of issue

Date of expiry

Source

Other Identifiers
Identifier type

Identifier value

Case ID

456789456

CEAC barcode

8978335

Client visa details
Applicant Category

NIV

-

Non-Immigrant Visa

Health case details: Record results
Client declaration
* I declare that NAME (or their parent/guardian) has read and understands the information provided by the U.S. Department of State regarding eMedical and has agreed to his/her medical information being submitted electronically to the
Department, with this consent to be recorded by this clinic in eMedical.

Name of parent/guardian
Pre exam



Relationship to the client

Health case details



View client declaration

Confirm Identity



All Exams
All exams summary

Select an Option

Contact Channels

?

Current exams
501 Medical Examination
Confirm identity

Delete

Past Medical History
Basic questions
Detailed questions
Review exam details
Classification and Examiner
Declaration

Contact Channel

Contact details

Primary

Comments

eMail (Personal)

applicant@gmail.com

Yes

-

Address (Home)

Somewhere, Else, ACT, AUSTRALIA

Yes

-

Address (Intended)

298 West 33rd Street,New York, NY 10001, USA

No

-

Edit

502 Chest X-ray Examination
Pregnancy declaration
Confirm identity
Attach X-ray image
Chest X-ray findings
Review exam details
Examiner Declaration
603 Respiratory Specialist
investigation on current state
of tuberculosis
607 Continued anti-tuberculosis
treatment
712 Syphilis test (VDRL or RPR)
713 Gonorrhea
714 Hansen’s Disease
719 TB screening test – TST
or IGRA

Paperwork Reduction Act statement
Public reporting burden for this collection of information is estimated to average 60 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
INA Section 222(f) provides that visa issuance and refusal records 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. The U.S. Department of State uses the information provided on this form primarily to determine an individual’s eligibility for a U.S. visa. Certified copies of visa records may be made available to a court which certifies that the
information contained in such records is needed in a case pending before the court. 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. Although furnishing this information is voluntary , individuals who fail to submit this form or who do not
provide all the requested information may be denied a U.S. visa or cause processing delays.

951 Vaccinations
106 Mental Health report
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501 Medical Examination: Past medical history
Answer ‘No’ to all

Record Medical History (Past or present)
General
Illness or injury requiring hospitalization (including psychiatric)

*

Not selected

No

Yes

Hypertension

*

Not selected

No

Yes

Congestive heart failure or coronary artery disease

*

Not selected

No

Yes

Arrhythmia

*

Not selected

No

Yes

Rheumatic heart disease

*

Not selected

No

Yes

Congenital heart disease

*

Not selected

No

Yes

Current Tobacco use

*

Not selected

No

Yes

Former Tobacco use

*

Not selected

No

Yes

Asthma

*

Not selected

No

Yes

Chronic obstructive pulmonary disease

*

Not selected

No

Yes

History of Tuberculosis

*

Not selected

No

Yes

No

Yes

Cardiology

Pulmonology

Diagnosed (mm-yyyy)

Treatment

?

Treatment completed (mm-yyyy)
Add

- Select an option -

Not selected
Anatomic site of disease

*

Treatment

*

Not selected

No

Fever

*

Not selected

No

Cough

*

Not selected

No

Yes

Night sweats

*

Not selected

No

Yes

Weight loss

*

Not selected

No

Yes

Signs or symptoms of TB

*

Not selected

No

Yes

Recent contact with known TB case

*

Not selected

No

Yes

Page-54: Record results

Contact’s Name

Current

Started but not finished

Completed

Yes

*

Contact’s case or Alien number, if known

Pre exam



Health case details



Confirm Identity



All Exams
All exams summary

Select an Option

Applicant’s relationship to Contact

*

Provide details

*

Date contact ended

*

20Jun2015

Type of source case TB

*

Select an Option

Psychiatry
*

Not selected

No

Yes

Major impairment in learning, intelligence, self-care, memory or communication

*

Not selected

No

Yes

Use of substances other than those required for medical reasons

*

Not selected

No

Yes

Substance use or substance induced disorders of substances on the Controlled Substances Act (CSA)

*

Not selected

No

Yes

Detailed questions

Referral made to mental health specialist

*

Not selected

No

Yes

Review exam details

Any physical or mental disorder (excluding addiction or abuse of specific substance on the Controlled Substances Act,
but including other substance-related disorder)
*

Not selected

No

Yes

Not selected

No

Yes

Not selected

No

Yes

Current exams
501 Medical Examination
Confirm identity
Past Medical History
Basic questions

Classification and Examiner
Declaration
502 Chest X-ray Examination
Pregnancy declaration

Psychological/Psychiatric Disorder (including major depression, bipolar disorder or schizophrenia)

Class A, with harmful behaviour

*

List disorder(s)

*

Confirm identity
Attach X-ray image
Chest X-ray findings
Review exam details
Examiner Declaration
603 Respiratory Specialist
investigation on current state
of tuberculosis

Class B, without harmful behaviour

*

List disorder(s)

*

Addiction or abuse of specific substance on the Controlled Substances Act

*

Not selected

No

Yes

607 Continued anti-tuberculosis
treatment

Class A

*

Not selected

No

Yes

712 Syphilis test (VDRL or RPR)

List substance(s)

*

Class B, in remission

*

Not selected

No

Yes

List substance(s)

*

713 Gonorrhea
714 Hansen’s Disease
719 TB screening test – TST
or IGRA
951 Vaccinations
106 Mental Health report
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501 Medical Examination: Past medical history
Substance use or substance induced disorders of substances not on the CSA (including alcohol)

*

Not selected

No

Yes

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

*

Not selected

No

Yes

Ever had thoughts of harming yourself

*

Not selected

No

Yes

*

Not selected

No

Yes

*

Not selected

No

Yes

*

Not selected

No

Yes

Ever acted on those thoughts
Ever had thoughts of harming others
Ever acted on those thoughts

Neurology
History of stroke

Not selected

No

Yes

Seizure disorder

Not selected

No

Yes

Obstetrics
Pregnant, on the day of exam?

Not selected

Estimated Delivery Date

No

Yes

25Jun2012

*

LMP
Fundal Height (in cm)
Normal / Abnormal

*

Previous live births:

*

Birth dates:

Not selected

Normal

Abnormal

No

Yes

None

*

Dd Mmm yyyy
Dd Mmm yyyy
Dd Mmm yyyy

?

Sexually Transmitted Diseases
Syphilis

*

Not selected

?

Previous treatment for Syphilis
Treatment

Medication

Start

End

dd Mmm yyyy dd Mmm yyyy

Dose

Frequency

10mg

1x3/day

Gonorrhea
Previous treatment for Gonorrhea

Not selected

*

Treatment

Medication

Start

End

dd Mmm yyyy dd Mmm yyyy

Side effects

Dose

Frequency

10mg

1x3/day

No

Yes

?

Side effects

Endocrinology
Diabetes

*

Not selected

No

Yes

Thyroid disease

*

Not selected

No

Yes

Anemia

*

Not selected

No

Yes

Sickle Cell Disease

*

Not selected

No

Yes

Thalassemia

*

Not selected

No

Yes

Other hemoglobinopathy

*

Not selected

No

Yes

Hematologic/Lymphatic

Hansen’s Disease
Hansen’s Disease history

*

Diagnosed (mm yyyy)

*

Not selected

No

?

Yes

20Jun2015
20Jun2015

Treatment completed (mm yyyy)
Initial Diagnosis
Test name

*

Date result reported

*

20Jun2015

Test Result

*

Not selected

Positive

Made by

*

Not selected

Panel Physician

Negative
Non-panel physician prior to current evaluation

2005

Year of diagnosis

*

Type of Hansen’s disease

*

Not selected

Multibacillary

Paucibacillary

Treatment
*

Not selected

None

Partial ( ≥7 days)

Treated by panel physician?

*

Not selected

No

Yes

Referred for treatment?

*

Not selected

No

Yes

Referral facility

*

Treatment

501 - Past medical history - US: Record results

Pre exam



Health case details



Confirm Identity



Treatment

Medication

Start

dd Mmm yyyy dd Mmm yyyy

Dose

Frequency

10mg

1x3/day

Side effects

Other
An abnormal or reactive HIV blood test

All Exams

End

Completed

Diagnosed (mm-yyyy)
Malignancy

All exams summary

*

Not selected

No

Yes

*

Not selected

No

Yes

?

*

Specify

Current exams
501 Medical Examination
Confirm identity

Kidney or Bladder disease

*

Not selected

No

Yes

Medical history
History
Past medical

Chronic liver disease (Including hepatitis B or C)

*

Not selected

No

Yes

Food or drug allergies

*

Not selected

No

Yes

*

Not selected

No

Yes

*

Not selected

No

Yes

*

Not selected

Basic questions
Detailed questions

Specify

Review exam details
Classification and Examiner
Declaration
502 Chest X-ray Examination
Pregnancy declaration
Confirm identity

Other medical conditions requiring treatment
Specify

Attach X-ray image
Chest X-ray findings
Review exam details

Disabilities (including loss of arms or legs)

Examiner Declaration
603 Respiratory Specialist
investigation on current state
of tuberculosis
607 Continued anti-tuberculosis
treatment
712 Syphilis test (VDRL or RPR)

Specify

Current medications (List all current medications)

Previous surgeries (List all previous surgeries)

713 Gonorrhea
714 Hansen’s Disease
719 TB screening test – TST
or IGRA

Doctor declaration
Applicant appears to be providing unreliable or false information

No

Yes

Specify

951 Vaccinations
106 Mental Health report
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501- Medical
Examination:
questions
501
Basic Questions
- US:Basic
Record
results

Basic Questions
Exam date

Height and Weight
Height
In centimeters

Weight
In kilograms

BMI
Pre exam



Blood Pressure

Health case details



Initial blood pressure
Systolic

Confirm Identity
All Exams
All exams summary
Current exams
501 Medical Examination
Confirm identity
Past Medical History
Basic questions
questions
Basic
Detailed questions
Review exam details
Classification and Examiner
Declaration
502 Chest X-ray Examination
Pregnancy declaration
Confirm identity



Diastolic
Pulse

Vital signs
Temperature
In oC

Respiratory rate
/ min

Eyes
Visual acuity testing

*

Left eye:

*

6/36

Right eye:

*

6/24

Not selected

Uncorrected

Corrected

No (applicant under 4)

Attach X-ray image
Chest X-ray findings
Review exam details
Examiner Declaration
603 Respiratory Specialist
investigation on current state
of tuberculosis
607 Continued anti-tuberculosis
treatment
712 Syphilis test (VDRL or RPR)
713 Gonorrhea
714 Hansen’s Disease
719 TB screening test – TST
or IGRA
951 Vaccinations
106 Mental Health report
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501 Medical
- Detailed
Examination:
Questions - Detailed
US: Record
questions
results
Answer ‘Normal’ to all

All systems
General appearance

*

Not selected

Normal

Abnormal

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

*

Not selected

Normal

Abnormal

Cardiovascular
system rub)
Heart (S1, S2, murmur,

*

Not selected

Normal

Abnormal

Provide details

Pre exam



Health case details



Confirm Identity
All Exams
All exams summary
Current exams
501 Medical Examination
Confirm identity



*

Respiratory
system
Lungs (auscultation)

*

Not selected

Normal

Abnormal

Nervous system: Sequalae of stroke or cerebral palsy, other neurological disabilities

*

Not selected

Normal

Abnormal

Gastrointestinal
system
Abdomen (including
liver, spleen)

*

Not selected

Normal

Abnormal

mobility for all persons 60 or more years of age)
Musculoskeletal system (including gait)

*

Not selected

Normal

Abnormal

Extremities (including pulses, edema)

*

Not selected

Normal

Abnormal

Hematologic

*

Not selected

Normal

Abnormal

*

Not selected

Normal

Abnormal

Brain and cognition
Mental and
status
(including
mood, intelligence, perception, thought processes, and behaviour during examination)
Mental
cognitive
status

Eyes, ears, nose, throat and mouth

Past Medical History

Eyes

*

Not selected

Normal

Abnormal

Basic questions

Nose, mouth and throat (include dental)

*

Not selected

Normal

Abnormal

Detailed questions
questions
Detailed

Hearing and ears

*

Not selected

Normal

Abnormal

Not selected

Normal

Abnormal

Not selected

Normal

Abnormal

Review exam details
Classification and Examiner
Declaration

Miscellaneous

502 Chest X-ray Examination

Exposed Skin
Hearing

*

Pregnancy declaration

Lymph nodes

*

Confirm identity
Attach X-ray image
Chest X-ray findings

Remarks

Review exam details
Examiner Declaration
603 Respiratory Specialist
investigation on current state
of tuberculosis
607 Continued anti-tuberculosis
treatment
712 Syphilis test (VDRL or RPR)
713 Gonorrhea
714 Hansen’s Disease
719 TB screening test – TST
or IGRA
951 Vaccinations
106 Mental Health report
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501 Medical Examination: Classification and Examiner Declaration

Provide Classification
Please complete the 501 Medical Examination. If you have completed the exam and you are ready to provide the Classification, press the ‘Prepare for Classification’ button
Prepare for classification

Classification
Class A Conditions
Tuberculosis disease (1A1)
Syphilis, untreated (1A1)
Gonorrhea, untreated (1A1)
Hansen’s Disease, untreated multibacillary or paucibacillary (1A1)
Any physical or mental disorder (excluding addiction or abuse of specific substance on the Controlled Substances Act but including other substance-related disorder)
with harmful behavior or history of such behavior likely to recur (1A3)
Addiction or abuse of specific substance on the Controlled Substances Act (1A4)

?

Immigrant visa applicant refuses vaccinations (1A2)
Class B Conditions
Tuberculosis
B0 TB, Pulmonary

?

B1 TB, Pulmonary
B1 TB, Extrapulmonary

?

Anatomic site of disease

*

Treatment

*

Not selected

No

Current

Started but not finished

Completed

?

B2 TB: LTBI evaluation
LTBI treatment

*

Not selected

No

Current

Treated by Panel Physician

*

Not selected

No

Yes

No

Window prophylaxis

LTBI regimen

*

Details

*

Treatment started

Started but did not finish

Completed

Select an Option

*

Treatment ended

?

B3 TB: Contact
501 - Classification:
RecordEvaluation
results
Preventative treatment

*

Prophylaxis Regime

*

Details

*

Treatment started

*

Not selected
Select an Option

Treatment ended

Pre exam



Health case details



Confirm Identity



Syphilis, treated within last year
Gonorrhea, treated within last year
Hansen’s Disease
Treated multibacillary
Treated paucibacillary
Any physical or mental disorder (excluding addiction or abuse of specific substance on the Controlled Substances Act but including other substance-related disorder)
without harmful behavior or history of such behavior unlikely to recur
Sustained, full remission of addiction or abuse of specific substance on the Controlled Substances Act

All Exams
All exams summary
Current exams
501 Medical Examination
Confirm identity
Past Medical History

Class B Other
Details

*

Mandatory if ticked

Basic questions
Detailed questions
Review exam details
Classification
Classification and
and Examiner
Examiner
Declaration
Declaration
502 Chest X-ray Examination

No apparent defect, disease or disability

Remarks

Pregnancy declaration
Confirm identity

General supporting comments

Attach X-ray image
Chest X-ray findings
Review exam details
Examiner Declaration
603 Respiratory Specialist
investigation on current state
of tuberculosis
607 Continued anti-tuberculosis
treatment
712 Syphilis test (VDRL or RPR)
713 Gonorrhea
714 Hansen’s Disease
719 TB screening test – TST
or IGRA
951 Vaccinations
106 Mental Health report

If you wish to update the examination answers then press the ‘Edit exam’ button.

Edit exam

Examiner declaration
I attest that I performed this examination, have reviewed all test results, and that the medical classification is correct in accordance with the Centers for Disease Control
and Prevention's Technical Instructions for panel physicians.
I further attest that I have a current panel physician agreement with the Department of State.
Completed by

Date of declaration

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Prepare for classification

Classification
Class A Conditions
Tuberculosis disease (1A1)
Syphilis, untreated (1A1)
Gonorrhea, untreated (1A1)
501 - Classification
('happy'untreated
case): Record
resultsor paucibacillary (1A1)
Hansen’s Disease,
multibacillary
Any physical or mental disorder (excluding addiction or abuse of specific substance on the Controlled Substances Act but including other substance-related disorder)
with harmful behavior or history of such behavior likely to recur (1A3)
Addiction or abuse of specific substance on the Controlled Substances Act (1A4)
Immigrant visa applicant refuses vaccinations (1A2)
Class B Conditions
Tuberculosis
B0 TB, Pulmonary
Pre exam



Health case details



Confirm Identity



All Exams
All exams summary
Current exams
501 Medical Examination



Confirm identity



Past Medical History



Basic questions



Detailed questions



Review exam details
Classification
Classification and
and Examiner
Examiner
Declaration
Declaration



502 Chest X-ray Examination



Pregnancy declaration



Confirm identity



Attach X-ray image



Chest X-ray findings



Review exam details



Examiner Declaration



B1 TB, Pulmonary
B1 TB, Extrapulmonary
B2 TB: LTBI evaluation
B3 TB: Contact Evaluation
Syphilis, treated within last year
Gonorrhea, treated within last year
Hansen’s Disease
Treated multibacillary
Treated paucibacillary
Any physical or mental disorder (excluding addiction or abuse of specific substance on the Controlled Substances Act but including other substance-related disorder)
without harmful behavior or history of such behavior unlikely to recur
Sustained, full remission of addiction or abuse of specific substance on the Controlled Substances Act
Class B Other
No apparent defect, disease or disability

Remarks
General supporting comments

106
report
603 Psychiatrist’s
Respiratory Specialist

investigation on current state
712 Syphilis test (VDRL or RPR) 
of tuberculosis
713 Gonorrhea
607 Continued anti-tuberculosis 
treatment
951
Vaccinations

712 Syphilis test (VDRL or RPR)
713 Gonorrhea
714 Hansen’s Disease
719 TB screening test – TST
or IGRA
951 Vaccinations
106 Mental Health report

If you wish to update the examination answers then press the ‘Edit exam’ button.

Edit exam

Examiner declaration
I attest that I performed this examination, have reviewed all test results, and that the medical classification is correct in accordance with the Centers for Disease Control
and Prevention's Technical Instructions for panel physicians.
I further attest that I have a current panel physician agreement with the Department of State.
Completed by

Date of declaration

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502 Chest
- Pregnancy
X-ray Examination:
declaration: Record
Pregnancy
results
Declaration

Is
Pregnancy,
the client pregnant?
current

Not selected

Estimated
date
(mm-dd-yyyy)
When
doesdelivery
the client
expect
to give birth?
Does the client wish to proceed with the required X-ray examination(s)?

Pre exam



Health case details



Confirm Identity



No

Yes

No

Yes

25Jun2012
Not selected

All Exams
All exams summary
Current exams
501 Medical Examination
Confirm identity
Past Medical History
Basic questions
Detailed questions
Review exam details
Classification and Examiner
Declaration
502 Chest X-ray Examination
Pregnancy declaration
Confirm identity
Attach X-ray image
Chest X-ray findings
Review exam details
Examiner Declaration
603 Respiratory Specialist
investigation on current state
of tuberculosis
607 Continued anti-tuberculosis
treatment
712 Syphilis test (VDRL or RPR)
713 Gonorrhea
714 Hansen’s Disease
719 TB screening test – TST
or IGRA
951 Vaccinations
106 Mental Health report
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502 Chest
- Attach
X-ray
X-ray
Examination:
images: Record
Attach
results
x-ray images
Attach x-ray images
Date of x-ray

*

Attachments
?

Link to existing
Delete
Pre exam



Health case details



Confirm Identity



?

Add new

Document type

Details

Attachment type

Sending method

File name

Edit

No documents have been attached

All Exams
All exams summary
Current exams
501 Medical Examination
Confirm identity
Past Medical History
Basic questions
Detailed questions
Review exam details
Classification and Examiner
Declaration
502 Chest X-ray Examination
Pregnancy declaration
Confirm identity
Attach X-ray images
image
Chest X-ray findings
Review exam details
Examiner Declaration
603 Respiratory Specialist
investigation on current state
of tuberculosis
607 Continued anti-tuberculosis
treatment
712 Syphilis test (VDRL or RPR)
713 Gonorrhea
714 Hansen’s Disease
719 TB screening test – TST
or IGRA
951 Vaccinations
106 Mental Health report
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502 Chest
- ChestX-ray
X-rayExamination:
Findings: Record
Findings
results

Record results
Exam date

*

Findings

*

Mark all that apply

Pre exam



Health case details



Confirm Identity



Abnormal

Infiltrate or consolidation

Pleural effusion

Discrete nodule(s) without calcification

Reticular markings suggestive of fibrosis

Hilar / mediastinal adenopathy

Volume loss or retraction

Cavitary lesion

Miliary findings

Irregular thick pleural reaction

Nodule or mass with poorly defined margins (such as tuberculoma)

Discrete linear opacity

Other

Smears and Cultures not required
Cardiac

All exams summary

Musculoskeletal

Current exams

Other

501 Medical Examination

Smooth pleural thickening (if at CPA, must confirm is not effusion [do lateral or decubitus radiograph or ultrasound])
Diaphragmatic tenting
Single or scattered calcified pulmonary nodule(s)
Calcified lymph node(s)

Confirm identity
Basic questions

Normal

Suggests Tuberculosis (will require Smears and Cultures)

All Exams

Past Medical History

Not selected

Remarks

Detailed questions
Review exam details
Classification and Examiner
Declaration
502 Chest X-ray Examination
Pregnancy declaration
Confirm identity
Attach X-ray image
Chest X-ray findings
Review exam details
Examiner Declaration
603 Respiratory Specialist
investigation on current state
of tuberculosis
607 Continued anti-tuberculosis
treatment
712 Syphilis test (VDRL or RPR)
713 Gonorrhea
714 Hansen’s Disease
719 TB screening test – TST
or IGRA
951 Vaccinations
106 Mental Health report
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502 Chest
- Examiner
X-rayDeclaration:
Examination:
Record
Examiner
results
Declaration

Prepare for Declaration

General supporting comments
Pre exam



Health case details



Confirm Identity



All Exams

Prepare for Declaration

If you wish to update the examination answers then press the ‘Edit exam’ button

Edit Exam

All exams summary
Current exams
501 Medical Examination
Confirm identity
Past Medical History

Examiner declaration
I declare that this chest x-ray examination report is a true and correct record of my findings

Basic questions
Detailed questions
Review exam details

Completed by
Date of declaration

Classification and Examiner
Declaration
502 Chest X-ray Examination
Pregnancy declaration
Confirm identity
Attach X-ray image
Chest X-ray findings
Review exam details
Examiner
Examiner Declaration
Declaration
603 Respiratory Specialist
investigation on current state
of tuberculosis
607 Continued anti-tuberculosis
treatment
712 Syphilis test (VDRL or RPR)
713 Gonorrhea
714 Hansen’s Disease
719 TB screening test – TST
or IGRA
951 Vaccinations
106 Mental Health report
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603 Respiratory Specialist investigation on current state of tuberculos: Record results

Record results
Exam date

*
Investigation required to determine the current status regarding tuberculosis. Please include the following information:
-Results of 3 current smears and cultures (sputum samples taken on 3 consecutive working mornings, or other appropriate specimens as clinically indicated) and cultures for
Mycobacterium tuberculosis (plus drug susceptibility testing (DST) if cultures are positive),
-Old chest x-rays for comparison (if available). Reports can be submitted if images available are not digital,
-Any previous reports regarding any treatment of tuberculosis.

Exam description

603
Respiratory
investigation on current state of tuberculos: Record results
Sputum
SmearsSpecialist
and Cultures
Sputum Smear Laboratory

*

Sputum Culture Laboratory

*

?

Pre exam



Health case details



Specimen obtained

Test date

Test name

Result

Remarks

Sputum Smear

Positive

-

Culture

Negative

Path lab closed

Recording of Laboratory Tests is complete
Clinical diagnosis of TB?

Confirm Identity
All Exams
All exams summary
Current exams
501 Medical Examination



*

Not selected

Yes

No

Drug susceptibility tests
Method of DST

*

Date specimen obtained

*

Date specimen reported

*

Drug Susceptibility Test Laboratory

*

Select an option

Confirm identity
Past Medical History

Basic questions

?

Detailed questions
Review exam details
Classification and Examiner
Declaration

Drug

Finding

Isoniazid

502 Chest X-ray Examination
Pregnancy declaration
Confirm identity
Attach X-ray image

Molecular tests
Used in addition?

*

Not selected

Yes

No

Chest X-ray findings
Review exam details

Molecular Test

Mycobacteruim Tuberculosis

Rifampin resistance

Isoniazid resistance

Hain Line Probe Assay

GeneXpert

Examiner Declaration
603 Respiratory Specialist
investigation on current state
of tuberculosis
state
of tuberculosis
607 Continued anti-tuberculosis
treatment
712 Syphilis test (VDRL or RPR)
713 Gonorrhea
714 Hansen’s Disease
719 TB screening test – TST
or IGRA

Attachments
General Supporting Comments

951 Vaccinations
106 Mental Health report
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+

Add / Edit Molecular test
Molecular test

*

Other

*

Select an Option

Mycobacterium Tuberculosis

*

Not selected

Positive

Negative

Not tested

Rifampin Resistance

*

Not selected

Positive

Negative

Not tested

Isoniazid Resistance

*

Not selected

Positive

Negative

Not tested
Cancel

OK

X

607 Continued tuberculosis treatment: Record results

Record results
Exam date

*

Exam Description

Positive sputum smears/cultures or commencement of TB treatment advice noted with thanks. Await final report with repeat chest x-ray upon completion of TB treatment.

Treatment
Treatment

Medication

Start

dd Mmm yyyy dd Mmm yyyy

Treated at approved DOT site?

*

End

Not selected

No

Dose

Frequency

10mg

1x3/day

Side effects

Yes

Recording of Treatment is complete

Post-treatment Clinical diagnosis (for Radiologist to complete)
Date radiograph obtained

*

Findings suggestive of TB?

*

Findings present

20Jun2017
Not selected

No

Yes

Suggests Tuberculosis

*

Infiltrate or consolidation

Pleural effusion

Discrete nodule(s) without calcification

Reticular markings suggestive of fibrosis

Hilar / mediastinal adenopathy

Volume loss or retraction

Cavitary lesion

Miliary findings

Irregular thick pleural reaction

Nodule(s) or mass with poorly defined margins (such as tuberculoma)

Discrete linear opacity

Other

Does not suggest Tuberculosis
Cardiac

Smooth pleural thickening (if at CPA, must confirm is not effusion [do lateral or decubitus radiograph or ultrasound])

Musculoskeletal

Diaphragmatic tenting

Other

Single or scattered calcified pulmonary nodule(s)
Calcified lymph node(s)

Remarks

Interpreted by

Date radiograph interpreted

23Jun2017

*

I declare that these are a true and correct record of my findings

Sputum Smears and Cultures
Sputum Smear Laboratory

*

Sputum Culture Laboratory

*

?
Date Specimen obtained

Specimen Report date

Test name

Result

Remarks

Sputum Smear

Positive

-

Culture

Negative

Path lab closed

Recording of Laboratory Tests is complete
Clinical diagnosis of TB?

Not selected

*

Yes

No

Drug susceptibility tests
607
Continued
tuberculosis treatment: Record
results
Select
an option
Method
of DST
*
Date specimen obtained

*

Date specimen reported

*

Drug Susceptibility Test Laboratory

*

Required for first-line DST

Pre exam



Health case details



Confirm Identity



All Exams

Isoniazid

*

Not selected

Susceptible

Resistant

Rifampin

*

Not selected

Susceptible

Resistant

Ethambutol

*

Not selected

Susceptible

Resistant

Pyrazinamide

*

Not selected

Susceptible

Resistant

Required for multidrug-resistant cases
Ethionamide

*

Not selected

Susceptible

Resistant

Capreomycin

*

Not selected

Susceptible

Resistant

Amikacin

*

Not selected

Susceptible

Resistant

Para-aminosalycylic acid (PAS)

*

Not selected

Susceptible

Resistant

Past Medical History

Fluoroquinolone

*

Not selected

Susceptible

Resistant

Basic questions

Specify

*

All exams summary
Current exams
501 Medical Examination
Confirm identity

Detailed questions
Review exam details
Classification and Examiner
Declaration
502 Chest X-ray Examination
Pregnancy declaration
Confirm identity
Attach X-ray image
Chest X-ray findings
Review exam details
Examiner Declaration
603 Respiratory Specialist
investigation on current state
of tuberculosis
607 Continued tuberculosis
anti-tuberculosis
treatment
712 Syphilis test (VDRL or RPR)
713 Gonorrhea
714 Hansen’s Disease
719 TB screening test – TST
or IGRA
951 Vaccinations
106 Mental Health report

Susceptibility to other drugs
Other drug 1
Finding 1

Not selected

Susceptible

Resistant

Not selected

Susceptible

Resistant

Not selected

Susceptible

Resistant

Not selected

Susceptible

Resistant

Not selected

Susceptible

Resistant

Other drug 2
Finding 2
Other drug 3
Finding 3
Other drug 4
Finding 4
Other drug 5
Finding 5

Attachments
General Supporting Comments
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712 Syphilis test (VDRL or RPR): Record results

Record results
Exam date

*
Syphilis testing and results are required

Exam description

Screening

Pre exam



Health case details



Confirm Identity



All Exams
All exams summary
Current exams
501 Medical Examination
Confirm identity
Past Medical History

Test name

*

Date specimen reported

*

Syphilis test result

*

Not selected

Titer

*

Select an Option

Non-reactive

Reactive

Non-reactive

Reactive

Confirmatory
Test name

*

Date specimen reported

*

Repeat Syphilis test result

*

Repeat Titer

*

Select an Option

Clinical judgment on result

*

Not selected

Stage of Syphilis

*

Select an Option

Applicant elects to undergo treatment?

*

Not selected

Treatment warranted

Previous treatment, no new risk factors since treatment

Basic questions
Detailed questions
Review exam details
Classification and Examiner
Declaration
502 Chest X-ray Examination

Not selected

No

Yes

Treatment

?

Pregnancy declaration
Confirm identity

Treatment

Medication

Start

End

Attach X-ray image

dd Mmm yyyy dd Mmm yyyy

Dose

Frequency

10mg

1x3/day

Side effects

Chest X-ray findings
Review exam details

By Panel Physician?

*

Examiner Declaration

Not selected

No

Yes

Recording of Treatment is complete

603 Respiratory Specialist
investigation on current state
of tuberculosis
607 Continued anti-tuberculosis
treatment

Attachments

712 Syphilis test (VDRL or RPR)
713 Gonorrhea
714 Hansen’s Disease

General Supporting Comments

719 TB screening test – TST
or IGRA
951 Vaccinations
106 Mental Health report
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713 Gonorrhea: Record results

Record results
Exam Date

20Jun2015

*

Exam description

Record testing and treatment for Gonorrhea

Was laboratory testing performed

*

Not selected

No

Yes

Screening

Pre exam



Health case details



Confirm Identity



Date specimen reported

*

Test name

*

Gonorrhea test result

*

Applicant elects to undergo treatment?

*

Not selected
Not selected

Positive
No

Negative
Yes

All Exams
All exams summary

Treatment

Current exams
501 Medical Examination
Confirm identity
Past Medical History

Treatment

Medication

Start

dd Mmm yyyy dd Mmm yyyy

Basic questions

End

Dose

Frequency

10mg

1x3/day

Side effects

Recording of Treatment is complete

Detailed questions
Review exam details
Classification and Examiner
Declaration

Attachments

502 Chest X-ray Examination
Pregnancy declaration
Confirm identity

General Supporting Comments

Attach X-ray image
Chest X-ray findings
Review exam details
Examiner Declaration
603 Respiratory Specialist
investigation on current state
of tuberculosis
607 Continued anti-tuberculosis
treatment
712 Syphilis test (VDRL or RPR)
713 Gonorrhea
714 Hansen’s Disease
719 TB screening test – TST
or IGRA
951 Vaccinations
106 Mental Health report
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714 Hansen's Disease: Record results

Record results

?

Exam Date

*

Exam description

20Jun2015
Record diagnosis and treatment for Hansen’s Disease

Initial Diagnosis
Test name

*
20Jun2015

Pre exam



Date result reported

*

Health case details



Test Result

*

Not selected

Positive

Confirm Identity



Made by

*

Not selected

Panel Physician

Year of diagnosis

*

Type of Hansen’s disease

*

Not selected

Multibacillary

Paucibacillary

All Exams
All exams summary
Current exams
501 Medical Examination
Confirm identity

Negative
Non-panel physician prior to current evaluation

2005

Treatment

Past Medical History

Treatment

*

Not selected

None

Partial ( ≥7 days)

Basic questions

Treated by panel physician?

*

Not selected

No

Yes

Review exam details

Referred for treatment?

*

Not selected

No

Yes

Classification and Examiner
Declaration

Referral facility

*

Detailed questions

Completed

502 Chest X-ray Examination
Pregnancy declaration
Confirm identity

Treatment

Medication

Start

dd Mmm yyyy dd Mmm yyyy

End

Dose

Frequency

10mg

1x3/day

Side effects

Attach X-ray image
Chest X-ray findings
Review exam details
Examiner Declaration
603 Respiratory Specialist
investigation on current state
of tuberculosis

Attachments
General Supporting Comments

607 Continued anti-tuberculosis
treatment
712 Syphilis test (VDRL or RPR)
713 Gonorrhea
714 Hansen’s
Hansen's Disease
719 TB screening test – TST
or IGRA
951 Vaccinations
106 Mental Health report
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719 TB screening test - TST or IGRA: Record results

Record results
Exam Date (date drawn/applied)

*

Exam description

Pre exam



Health case details



Confirm Identity
All Exams
All exams summary
Current exams
501 Medical Examination
Confirm identity
Past Medical History
Basic questions
Detailed questions
Review exam details
Classification and Examiner
Declaration



Provide current results of tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA).

Type of exam conducted

*

Date of Reading

*

Millimetres of induration

*

Type of IGRA test

*

Result

*

*

TB antigen 1

*

TB antigen 2

*

Mitogen

Interferon Gamma Release Assay (IGRA)

27Jun2015

Select an Option
Not selected

Negative

Indeterminate, Borderline or Equivocal

Positive

*

T-Spot (Spot count for each)
Nil Control

*

Panel A

*

Panel B

*

Attach X-ray image

Tuberculin Skin Test (TST)

QuantiFERON (optimal density value [IU/ml] for each)
Nil

502 Chest X-ray Examination

Chest X-ray findings

Not selected

?

Pregnancy declaration
Confirm identity

20Jun2015

General supporting comments

Review exam details
Examiner Declaration
603 Respiratory Specialist
investigation on current state
of tuberculosis
607 Continued anti-tuberculosis
treatment
712 Syphilis test (VDRL or RPR)

Attachments
Link to existing
Delete

Add new
Document type

Details

Attachment type

Sending method

File name

?

Edit

No documents have been attached

713 Gonorrhea
714 Hansen’s Disease
719 TB screening test -– TST
TST
or IGRA
951 Vaccinations
106 Mental Health report
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951
951 Vaccination:
Vaccination: Record
Record results
results

Record results
Exam date

*

Exam Description

Disease

Pre exam



Health case details



Confirm Identity



All Exams

Applicant's full vaccination history is required

Vaccine

Vaccination history

Administered by clinic

Immunity Positive History

Waiver reasons

dd Mmm yyyy
dd Mmm yyyy
dd Mmm yyyy
dd Mmm yyyy

dd Mmm yyyy
dd Mmm yyyy
dd Mmm yyyy

dd Mmm yyyy

Contra-indicated
Flu Vaccine not available

Yes

Vaccination Documentation
Vaccination requirements complete?

*

Not selected

Reason

*

Select an Option

All exams summary

No

Yes

?

Refugee, follow to join Asylee/Refugee (V92/93) applicant not required to meet vaccination requirements

Current exams
501 Medical Examination

K-Visa applicant electing to not be vaccinated at this examination

Confirm identity
Other NIV applicant not required to meet vaccination requirements

Past Medical History
Basic questions

Immigrant Visa or Parolee applicant completed vaccination requirements

Detailed questions
Review exam details

K Visa applicant voluntarily completed vaccination requirements

Classification and Examiner
Declaration
502 Chest X-ray Examination

Current Pregnancy

Contra-indications

Pregnancy declaration

Immune compromised

Confirm identity

History of severe allergic reaction to vaccine or vaccine component

Attach X-ray image

Other severe reaction to vaccine

Chest X-ray findings
Review exam details

Current moderate to severe illness

Examiner Declaration

Other

603 Respiratory Specialist
investigation on current state
of tuberculosis
607 Continued anti-tuberculosis
treatment

Other Contra-indication

*

Remarks

712 Syphilis test (VDRL or RPR)
713 Gonorrhea
714 Hansen’s Disease

Attachments

719 TB screening test – TST
or IGRA
951 Vaccinations
Vaccination
106 Mental Health report
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106 Mental Health report: Record results

Record results
Exam date

*
Mental health questions must be answered by panel physician. If applicant is referred to a mental health specialist for further evaluation, panel physician must attach report.

Exam description

Any physical or mental disorder (excluding addiction or abuse of specific
substance on the Controlled Substances Act, but including other substancerelated disorder)
*
Pre exam



Health case details



Confirm Identity



All Exams

Class A, with harmful behaviour

*

List disorder(s)

*

Class B, without harmful behaviour

*

List disorder(s)

*

Not selected

No

Yes

Not selected

No

Yes

Not selected

No

Yes

All exams summary
Current exams
501 Medical Examination
Confirm identity
Past Medical History
Basic questions
Detailed questions
Review exam details
Classification and Examiner
Declaration

Addiction or abuse of specific substance on the Controlled Substances
Act

*

Current addiction or abuse?
Details of substances

Not selected

No

Yes

Not selected

No

Yes

Not selected

No

Yes

*

502 Chest X-ray Examination
Pregnancy declaration
Confirm identity
Attach X-ray image

Sustained, full remission?

*

Details of substances

*

Chest X-ray findings
Review exam details
Examiner Declaration
603 Respiratory Specialist
investigation on current state
of tuberculosis

Attachments

607 Continued anti-tuberculosis
treatment
712 Syphilis test (VDRL or RPR)

General Supporting Comments

713 Gonorrhea
714 Hansen’s Disease
719 TB screening test – TST
or IGRA
951 Vaccinations
106 Mental Health report
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