DS-1843 Medical History and Examination for Children age 12 and

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

DATE OF EXAM (mm-dd-yyyy)

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

1b. Chosen Name of Examinee

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

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

4. Place of Birth of Examinee
State

City
5a. Gender Identity - Choose all that apply

5b. Sex Assigned at Birth

Country

5c. Gender Pronouns - Choose all that apply:

Male

Male

He/Him/His

Female

Female

She/Her/Hers

Transgender

They/Them/Theirs

Non-binary
Another Gender

6. Status
Applicant

Employee

New Family Member
(Spouse, Newborn, Adoption)

Dependent Child

Spouse

7. Agency of Employee/Applicant/Sponsor
STATE

USAID

FCS

FAS

Other Government Agency
8. Health Insurance Plan

U.S. Agency for Global Media

9. Purpose of Exam

In-Service Exam
Separation Exam

Primary:

DoD Contractor

Contracting Company

Pre-Employment Exam

11. 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

10. Employment Status
Civil Service

LES

FS Officer

LNA

PSC Contractor

Fellow

3rd Party Contractor

EPAP

CA-EFM

Other

13. Special Assignment (If applicable)
TDY (Regional hub or CONUS based)

Alternate:

Iraq - List Post
Other ESCAPE Post(s) If yes, list

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

14. Post of Assignment and Estimated Dates of Arrival / Departure

Primary:

a. Proposed Post

Alternate:

b. Present Post

EDA
(mm-dd-yyyy)
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
12-2023

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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.

Does examinee have a history of:

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

Yes

No
25. Malaria, tropical or other infectious disease?
26. Any skin or nail disorder?

1. Frequent/severe headaches or migraines?

27. Cancer of any type?

2. Fainting, dizzy episodes, or syncope?

28. Any thickening or lump in breast, testicle?

3. Stroke, TIA or head injury?
4. Epilepsy, seizures or other neurologic disorders?
5. Eye or vision problems?
6. Ear, nose, throat problems; hearing loss, hoarseness?

IN THE PAST TWO (2) YEARS (for questions 29-35)
(parents - please answer for children < 18 years of age)
Yes

No

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?
15. Stomach, esophageal, or other intestinal problems?
16. Jaundice, hepatitis, or other liver disease?
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?
21. Are you pregnant?
22. Rheumatologic disorder?
23. Anemia?
24. Blood transfusion?

36. Is there any other medical or mental health condition not covered in questions 1 - 35?

29. Has the examinee been referred or evaluated for any
special educational services, accommodations, or
modifications (i.e.: IFSP, Early Intervention, IEP, 504 Plan)?
30. Has the examinee been in psychotherapy or counseling
for the treatment of anxiety, depression/mood problems,
psychological trauma, or any other mental health or
behavioral health concerns?
31. Has the examinee been prescribed medication for
depression, anxiety, mood, or stress, memory/attention, or
any other mental health or behavioral health symptoms?
32. Has the examinee 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 work
problems?
33. Has the examinee experienced symptoms of an eating
disorder, such as a history of binging, purging by selfinduced vomiting or use of laxatives, diuretics or enemas,
or restriction of food leading to extreme weight loss?
34. In the last 2 years has the examinee been hospitalized
for a mental health or behavioral health condition, or
engaged in self-injury or suicidal behavior?
35. Are you interested in a consultation with a Mental
Health specialist on managing Mental Health treatment
overseas?
Yes

No

IIA. Explanations required for "Yes" answers to questions 1-36. Attach additional sheets as needed.

DS-1843

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Name of Examinee

DOB

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

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 (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-1843

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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. 4), and provide follow-up recommendations (pg. 5).
• Medical Examiner must sign on page 5.
EXAMINEE / SPONSOR / PARENT
• All fields on page 1 through 3 must be filled out. Examinee or parent/employee sponsor must sign on page 3.
• 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.
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)
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Name of Examinee

DOB

X. 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

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:

XI. Assessment or Problem List

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

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

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

NOTICE: This form is not complete until all laboratory tests and results from section X 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)

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