Form PC-1790S Report of Medical Exam Form

Peace Corps
Report of
~edical
Examination

Sex M 0

Name (Last. F~rst,Middle Initial)

F0

Date of Birth (MO / DAY / YR)

Social Security Number

I

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1

/

Current Address Until

I

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/

I

1

PEACE CORPS USE ONLY
Action

Date

Initials

Cleared

-

MNQ

-

Telephone No.

I

(

Home/Permanent Address

Deferred
Restrictions

1 Teleohone

Type:

No.

)

I

E-mail

All sections must be completed

THIS SECTION TO BE COMPLETED BY APPLICANT

IV. Health Evaluation
A. Symptoms experienced within the past 12 months
Applicant:

Answer each question by checking either Yes or No.

Physician:

Please review this list. If any are marked "yes," please consider this a current problem requiring further comment or
work-up. Use space provided in Section X on page 4 (Summary and Comments) or additional pages if necessary, identified with the applicant's name and social security number.
Yes

Symptoms or problems

No

Yes

(Resolved)(Current) Physician comments

Frequent or severe headaches
Faint~ng
spells, blackouts or seizures
Vision problems (e.g., eye injuries, disorders, ~nflammation)
Hearing problems/loss
Persistent cough
Chest pain or chest pressure
Shortness of breath or wheezing
Repeated episodes of indigestion, heartburn, or stomach pain
Frequent diarrhea (colitis, Crohns)
Frequent constipation (irritable bowel syndrome)
Frequent or palnful urination
Blood In urine
Repeated episodes of back or neck pain
Muscle, bone, or joint Injuries
Painful or swollen jo~nts
Breast lump or mass or nipple discharge
Skin problems (e.g., eczema, dermatitis, psoriasis)
Change in color or size of a mole o r other growth
A sore that does not heal
Frequent sadness or feelings of depress~on
Frequent or severe nervousness or anxiousness
Frequent sleeplessness or insomnia
Use of cigarettes or other tobacco products
(Females) Gynecologic symptoms or disorders

Peace Corps - Report ofMedical Examinatton

PC-OMS-1790s(Rev. 1/2007)

Page 1 of 4

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SSN (

B. Health issues/problems (not described in Section A)

D None

C. Family history
List family members (mother, father, siblings) w h o have had any of t h e f o l l o w ~ n gillnesses o r problems:

9 Alcoholism

Cardiovascular disease

a Diabetes

a Mental ~llness

D Cancer

n Other (specify)

a High blood pressure
D. List all current medications, including over-the-counter medications/supplements and herbals
Name

Dose

Frequency

Ll None

E. Allergies and hypersensitivities
Allergies

Description of reaction

Treatment

.

Date of last reaction

Medications
Food
Other

3 None

*

*

Important I certqY that the above information is accurate and complete. I understand that the Peace Corps may ~ e r ?the~
information provided by me and my doctors. I understand that giving false or incomplete information will delay processing my application and
may result in disqualification from or termination of Peace Corps service.
HlPAA and Privacy Act Notice
This information is collected under the authority of the Peace Corps
Act, 22 U.S.C. 2501 et seq., for the purposes of determining medical and
other eligib~lityfor Peace Corps service. Disclosure of this information
is voluntary, but without it the Peace Corps will be unable to provide
a medical clearance for service. This information may be used for the
routine uses descr~bedin the Privacy Act, 5 USC 552a. and in the
Federal Register at 65 Fed. Reg. 53,722 (September 5, 2000) and 50
Fed. Reg. 1950, 1962 (January 14, 1985) regarding the Peace Corps
system of records PC-17 (Volunteer Records). It may also be used in
compliance with the Health Insurance Portability and Accountability Act
(HIPAA) and any currently effective authorizations.
Peace Corps -- Repol-! of Medical Examination

Signature

Date

PC-OMS-179oS(Rev. 112007)

Page 2 of 4

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V. Measurements and Other Findings

feetl~nches

Ibs.

mm (resting)

VI. Clinical Examination

bpm (rest~ng)

wh~spertest or
other gross test

I

Uncorrected

Rlght 20/Left

20/-

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Corrected

R~ght 20/Left

20/-

attach eyeglass form
~fapp~cable

SECTION TO BE COMPLETED
BY EXAMINING PHYSICIAN

THIS

Check each item in appropriate column.
Normal Abnormal All systems must be examined.

Notes: Descr~beeach abnormality in detail. Enter item number
before each comment. Use addrt~onalsheets rf necessary.

1. Head and neck
2. Nose, slnuses
3. Mouth and throat
4. Thyroid
5. Ears
6 Eyes (include fundoscopic exam)
7. Lungs and chest
8. Breasts
9. Cardiac (rate, rhythm, heart sounds)
10 P e r ~ ~ h e rpulses
al
11 Abdomen
12. Prostate exam (men over 50 only)
13 Anus and rectum
14. Gen~talia(include hernia)
15. Pelvic exam (females only)
16. Sprne
17. Musculoskeletal
18. Neurolog~c
19.Sk~n,lymphatics
20.I d e n t ~ f ~ marks,
~ n g scars, tattoos
21.Psych~atr~c
(specify any sign~ficantcognit~ve
or behav~oralobservations)

VII. Laboratory Evaluation

I

Date read

Date

Albumin
Sugar

Tuberculin T

Blood

-

- Other

-

n

--

1Other Required Lab Test$

(Lab reports MUST be attached)

Do Not Report "Negative"

Size of induration must be recorded in box below,

a HIV Serology
n CBC

mm of induration

Date

Hepat~tisB surface Antigen

(Lab report MUST be attached)
Hepatitis B core Antibody

a Hepatitis C Antibody
a G6PD titer
PCOMS-1790s (Rev

1/2007)

(Prev~ousversrons of this form are obsolete)

Page 3 of 4

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VIII. Required Tests for Female
Applicants 40 Years and Older.
~m-s
-

(females only)

(Mach t-edialcgy rqwrt)

IX Required Immunizations:

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.

Physician Initial & Date Administration

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Tests for Applicants 50 Years
and Older.
(EKG trac~ngmust

1

be attached)

2k
-

Weg

s P o s

Neg-

.

b

x3

Neg-

lmmunizations History:
Do NOT Give These Immunizations.

-]

I

rnyslclan

Initials

1.Td Booster
(wlth In 5 years of the
Report of Med~cal

4. Yellow Fever

5. Hep B(l)

Examination)

6. Hep B(2)
2 Pollo Booster
(after age 18)

7. Hep q g )

8. Hep A(l)

3. MMR Booster

9 H ~ A(2)
P

(one booster needed
per Ilfetlme)

-

-

X. Summary of the Medical Examination and Additional Comments
Provide your summary and assessment of the medical examination. Comment on all abnormal flndlngs including recommendations
for evaluation and/or treatment required for the next three years of service in a developing country, If additional pages are required,
include applicant's name and social security number on each page.

I.Do you have any medical concerns about the applicant that might limit his/her assignment to a specific geograph~carea (e.g. mountainous terrain, high altitude, sun exposure, harsh environmental or climatic conditions, etc?) YES m NO m If yes, spec~fy

2.

In your opinion, does the applicant have any phys~calcondition(s) that would limit or restrict full participation in a Peace Corps program?
YES 0 NO P If yes, specify

3.Does the applicant have any psychological condition(s) or psychosocial needs that would limit or restrict full participation in a Peace Corps
program? YES m NO
If yes, specify

* Important *

Medical examination is complete only when:

Applicant has signed and dated statement on page 2.
Ph~s~cian
has signed and dated page 4.
Phvsiclan has Initialed all documented immunizations on page 4.
Required lab reports are attached.
PAP, EKG tracing and mammography report are attached (when indicated).

INCOMPLETE FORMS WILL BE
Peace Corps - Report af Medrcal Esaminakrion

(must be signed or msignedby a licensedM.D. or D.O. if e m p e r f o r d by other than M.D. or D.O.)

Phys~c~an
S~gnature/Tltle
Date

Phys~c~an
L~censeNumber/State

Physician Address and Phone Number

TO THE APPLICANT