Form DS-1622 Medical History and Examination for Children Age 11 and

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

MEDICAL HISTORY AND EXAMINATION

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

FOR CHILDREN AGE 11 AND YOUNGER
DATE OF EXAM (mm-dd-yyyy)

I. DEMOGRAPHIC INFORMATION
TO BE FILLED OUT BY EMPLOYEE/SPONSOR OR PARENT
1a. Name of Examinee (Last, First, MI)
1b. Chosen Name of Examinee

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

3a. Gender Identity - Choose all that apply

3b. Sex Assigned at Birth

3c. Gender Pronouns: - Choose all that apply:

Male

Male

He/Him/His

Female

Female

She/Her/Hers

Transgender

They/Them/Theirs

Non-binary
Another Gender

4. Place of Birth
State

City

Country

5. Full Name of Employee/Applicant/Sponsor

6. Agency of Employee/Applicant/Sponsor
STATE

USAID

FCS

Other Federal Agency
7. E-mail Address of Parent/Sponsor
(Where You can be Reached for the Next 90 days)
Primary:
Alternate:

9. Telephone Number of Parent/Sponsor
(Where You can be Reached for the Next 90 days)

FAS

U.S. Agency for Global Media

DoD Civilian

DoD Contractor

Contracting Company
8. Purpose of Exam
New Dependent (pre-employment, newborn, adoption)
In-Service Exam
Separation
10. Post of Assignment and Estimated Dates of Arrival / Departure
a. Proposed Post

EDA
(mm-dd-yyyy)

Primary:
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-1622
03-2023

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

Does your child currently, or have a hisory of:
Yes

Yes

No
1. Frequent/severe headaches?
2. Fainting, dizzy episodes, or syncope?
3. Seizures or neurologic disorders?
4. Eye or vision problems?
5. Ear, nose, or throat problems, including hearing loss?
6. Allergies or history of anaphylactic reaction?
7. Cough, wheeze, shortness of breath, asthma?
8. Murmurs, palpitations, or other heart problems?
9. Rheumatic fever?
10. Diabetes, thyroid, or other endocrine disorders?
11. Hormonal or metabolic disorder?
12. Stomach, esophageal, or other intestinal problems?
13. Jaundice, hepatitis, gallbladder or other liver disease?
14. Intestinal, rectal problems or hernia?
15. Anemia?
16. Blood transfusions?
17. Urinary or kidney problems, blood in urine?

No
26. Has your child been referred or evaluated for any
special educational services, accommodations, or
modifications (i.e.: IFSP, Early Intervention, IEP, 504 Plan)?
27. Has your child ever been in in psychotherapy or
counseling/coaching for the treatment of anxiety,
depression/mood problems, psychological trauma, or any
other mental health or behavioral health concerns?
28. Has your child ever been prescribed medication for
depression, anxiety, mood, or stress, attention, autism, or
any other mental health or behavioral health symptoms?
29. Has your child ever been diagnosed with an alcohol or
drug-related problem, been medically advised to reduce use
of a substance, or experienced a negative consequence
due to substance use, such as a legal infraction, medical or
school problems?
30 Has your child ever experienced symptoms of an eating
disorder, such as a history of binging, purging by
self-induced vomiting or use of laxatives, diuretics or
enemas, or restriction of food leading to extreme weight loss
or medical symptoms?

18. Cancer of any type?
19. Premature birth, pre or post-natal complications?

31. Has your child ever Engaged in self-harm or suicidal
behavior?

20. Joint, tendon or any orthopedic disorder?

32. Has your child ever been hospitalized or in a partial
hospital, day-treatment or residential treatment for a mental
health or behavioral health condition, or engaged in
self-injury or suicidal behavior?

21. Rheumatologic or immune disorder?
22. Malaria, tropical or other infectious disease?
23. Any recent unexpected weight loss/gain?
24. Any skin or nail disorder
25. History of positive TB skin test, IGRA, or Tuberculosis?

33. Is there anything else you would like to add about your
child's health or well-being that was not addressed in
questions 26-32?

II a. Explanation required for "yes" answers to questions 1-33. Attach additional document.

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III. LIST OF CURRENT MEDICATIONS (Include prescription, over the counter, vitamins, and herbs)

IV. HOSPITALIZATIONS/OPERATIONS/MEDICAL EVACUATIONS (Include all medical and psychiatric illnesses)
Name of Hospital
Illness or Operation

Date (mm-dd-yyyy)

Drug Or Other Allergies

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 PARENT OR SPONSOR (I certify I have read and understand the above statement.)
Date (mm-dd-yyyy)

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.
DS-1622

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Name of Examinee

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VI. INSTRUCTIONS FOR COMPLETION AND SUBMISSION OF DS-1622
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.
EMPLOYEE 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-1622.
• 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-1622 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: Newborn exam cannot be accepted if completed before four (4) weeks of age
1. Height/Length

2. Weight
in. or

lb. or

in. or

4. Blood Pressure (age 3 and Over)

kg.

cm.
percentile
5. Head Circumference
(18 months and under)

3. Pulse or HR (REQUIRED FOR ALL AGES,
INCLUDING, NEWBORNS)

percentile
6. Development Appropriate for Age

Yes

No

If NO, attach Development Screen and explain below with detail in assessment / plan
7. Gestational age at birth

cm.
percentile 8. Immunizations Reviewed

Yes

No

Immunizations current?

Yes

No

IX. PHYSICAL EXAM
Check each item as indicated.
Check "NE" if not evaluated.

Normal Abnormal

NE

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

1. General/Constitution
2. Development
3. Skin
4. Eyes
5. Ears/Nose/Throat
6. Neck/Thyroid
7. Lungs/Thorax
8. Cardivascular
(Record murmurs/abnormalities)
9. Abdomen
10. Genitalia
11. Anus/Rectum
12. Musculoskeletal/Spine/
Extremities (Note limitations)
13. Lymph nodes
14. Neurologic
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X. TUBERCULOSIS SCREENING
1. Tuberculin Skin Test : REQUIRED for ages 1 and over (unless previously positive) 2. Chest X Ray (PA and lateral) - Required only if TST >
For baseline status in a child who will live overseas in a likely endemic TB area.
10mm, positive IGRA or clinically indicated.
TST Results:

mm of induration

Date:

SUBMIT REPORT

IGRA Results:
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:

Results:

Date:

XI. Assessment or Problem List

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

Typed Name of Examiner

Signature of Examiner

Address

Telephone Number

DS-1622

Date (mm-dd-yyyy)

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