Form PC-1789 Health Status Review

D

P e a c e

Version 3.1

Please complete this Health Status Review and submit it at the
same time you submit your Peace Corps Application. Use the
enclosed envelope which is labeled "Medical Information
Envelope". If the envelope is missing use a plain envelope, write
"Medical History" on it, seal it, and send it with your application.

Before you can be accepted to serve overseas, Peace Corps needs to assess your health. This Health Status
Review Form is the first step in the medical review process. It will take about 15 minutes to complete the
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form. Your signature at the end of the form certifies that you have answered all questions accurately and
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A health condition you manage easily at home in the U.S. can become a significant medical issue in the
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countries Peace Corps serves. The Peace Corps Oflice of Medieal Services assesses your health in the
context of living conditions and medical care available in each country.
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For these reasons the types of medical questions asked and their level of detail are unlike medical histories
normally used for U.S. based health care.

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The Applicant Medical Screening Process is thorough, and it is important for you to answer these questions
accurately. You should know that we are able to medically clear more than 85% of all Applicants who
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complete the Medical Screening Process.

Be sure to answer ail questions.
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Fill in all dates where it is appropriate to do so.

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Fill in all bubbles completely.

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If you are unfamiliar with a condition AND believe you may have had it, please check vvith your family
physician or someone familiar with your m e d i d history before answering the question.
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Do not write explanatory notes on the form.
Do not wnd additional information about your health at this time.

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Pailure ln
answer 811questiune completelv may mean you will have to complete a new form.
PRTVACr ACT AND PUBLIC B U K U ~ NNOTICE - ihe Peace Corps is authorized by provisions of the Peace Corps ddt to coue
information regarding the suitability and qualifications of applicants for Peace Corps Service. The information you provide in this Heal ,
Status Review Form will be used to evaluate your suitability and qualifications to serve as a Volunteer. This form and the information you
provide will be kept in a System of Records called the Volunteer Applicant and Service Record System. Because Volunteer Records have
been kept according to Social Security Number (SSN) prior to 1975, we are authorized by the Privacy Act to request your SSN in order to
keep your records straight. Completing this form is voluntary; if you do not give us your SSN or any other information requested, we may be
unable to assess your suitability and qualifications for service. The Health Status Review Form is part of the Volunteer Application Kit
consisting of this form and the Volunteer Application. The routine uses set forth in the Volunteer Application's Privacy Act Notice -'I
Paragraph C,item 2 and Paragraph C, items 4-12 also apply to this form. In addition, information from the Health Status Review Form mi
be routinely disclosed in connection with claims under the Federal Employee's Compensation Act, to medical personnel treating or involved
in the treatment or care of an applicant, Trainee, or Volunteer and to the U.S. Ambassador or hidher designee itl Peace Corps countries, but
OMB 0420-05 19
only upon ~ ' ~ c~ f i . o ~ s - ~ , e , e d%&a!. e re3po-nsibility.
d ~ ~ q ~ ,
Version 3.1
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2. Social Security Number:
(It is very important that these bubbles
we filled in c o m ~ l e ba*
l ~ c0-Y.)

(Fill in bubbles for the first three
letters of your &
l name.)

Use a No. 2 pencil only. Do not use pen.
Make solid marks that fill the response completely.
Make no stray marks on this form.
Correct ark:

Incorrect Marks: @ @ 9@

M
G
EXAMPLE:

3. Are you:
0Female

lp?
0
Feb

0 Male

0sept

4. Are you a Returned

Nov

0 Oct

Peace Corps Volunteer?

OYB
yl_s Date:

!fq

QNO

6. Date of Birth:
7. ~ e i ~ inh Feet
t
and Inches: 8. Weight in Pounds:

If&..

Inches

9. Are you applying with
your spouse?
OYes
ONo

If YES, enter your spouse's
Social Security Number.

BE SURE YOU HAVE ANSWERED ALL, QUESI'IONS AND ENTERED ALL DATES REQUIRED BEM)1RE GOING ON.

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REMINDER: Do NOT write explanations on these pages.

10. Have you ever smoked or used tobacco
products?

Yes No

8 @

If YES, do you currently smoke or use tobacco:
every day @
some days @
former smoker only @

11. Do you currently wear dental braces?
(This does NOT include removable
orthodontic retainers, dentures, partial
plates or bridges.)
12. Do you have or have you ever had:
Chronic inner ear infection (otitis med
after age 15
Meniere's disease
Cyst of the inner ear
@

@
@
@

Yes No

5. Do you have n r have vnu ever had:
Glaucoma
Herpeg infection of the cornea (herpes
keratitia
Two or more ep~spqeaur opuc neur~u-eji
Chronic uveitis or iritir
Cataract surgery
Other vision correcting surgery, such as
RK, PRK, LASIK
Macular (urk@L?t$~~pg~~e18ti'oXi
(degeneration.of th
Retinal detachment

Yes No
@

63 @
0 @
@-

a
C

0 0

0 @

a

If any YES in Item 12, give date of
most recent symptoms or treatment.

16. Other than astigmatism or use of corrective
lenses, do you have or have you had any
pther condition or surgery of the eye not
listed in Item 15?

ye%.N~

17. Are you allergic to:
Sulfa drug ( ~ u c has Bactrim, Septra)
other medicatian(s)

Vgli

(3
,

a?
.

Pat

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@
O Q

:8

Peanuts
jShelLRsh
Other food(s)
Bee, wasp or other insect stin,
Hayfever or other environmental
allergies (such as grass, pollen, dust,
animal hair, etc.)

0 @

@ @

18. During an allergic reaction, have you ever had:
Yes N

13. Do you currently require the use of at least
one hearing aid?

Yes No

14. Other than tonsillectomy, childhood
tonsUUtis at-wisdom teeth extraction, do yon
have any condition or have you had any
surgery on your ears, nose, face, sinuses, jaw
or throat not listed in Items 11-13?

Yes No

.Q 8

@

@

Difficulty breamng
Loss of consciousness
-Severe swelling of your nose,
. ngue or
throat
Emergency treatment in a medkil fadity
for an allergic reaction

19. Do you have or have you ever had:

7

@ 4
0 f3

@ g
@ 0
Yes No:

Chronic bronchi@
Pneumonia more than once during the last
5 years
Emphysema or COPD
A collapsed lung @nearnothorax)
Removal of a lung or a lobe of the lung

s @

0 ;1$1
@ a

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BE SURE YOU HAVE ANSWERED ALL
QUESTIONS ANT3 ENTF,1R$lhALL DATES
REQUIRED BEFORE GUING ON.
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REIWINDER: Do NOT write explanations on these pages.

26. Do you have or have you ever had:
A heart murmur p r e w t &f&rm
Heart valve disease

20. Since age 15, have you ever:
Experienced .wheezing
Used an inhaler to prevent breathing
problems or to help you breathe
Been told p u

!

Yes NO

/ tmba.~a;ga&&g
A blood clot in the lu
pulmonary e
Thmmbophlebit3s
Problems caused by poor circulation

21. Do you have or have you had any
respiratory condition, lung conditim or
surgery not listed in Items 1!&2Q?

Yes No

22. Do you take prescription medkathn to
control your blood pressure?

Yes No

@

,

@_

O Q

23. Do yon take prescription medication for high Yes
cholesterol?

a

24. Have you ever had:
Ye
Angina
~
?
C
T 6%
A heart attack
e
Coronary artery or heart by-pass w
Coronary angioplasty ("balloon
angioplasty") or insertion of stent(s
Other heart sarrgery
Carotid artery surgery
Other surgery of the arteries

m

IPW

ft"es No

28. Do you have or have you had any other
heart or circulatory condition or surgery
not listed in Items 22-27?

Yes No

0 0

0 0

NO

@

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25. Do you have or have you ever had:
'Ifa NO
A pacemake1
.-Coronary arl
5
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Congestive hear0BxNure
A disturbance of heart rhythm (arrhythmia) @ @
An aneuwsm

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27. Other than aspirin, do you currently take
any bload-thinning (enti-esagulant)
medication, such as Warfarin s r Coumadin?

,

29. Do you have or have you ever had:
An esophageal stricture
Esophageal varicer
~Stomach or duodena
disease) '
Cirrhosis of the liver
Yellow jaundice (other than at birth)
Pancreatic disease
~ v e r t i c u ~ o s s / d i v e r t i c u l i t d ~
Part or all of your small or large intestine
removed
30. Do you now have:
A hernia of the groh (inguinal) or abdomenA colostomy or an ileostomy

%a# Hm

31. Have you had two or more episodes of a cyst
near the rectum (pilonidal cyst)?

yes

32. Do you have or have you had any other
conditions or surgery of the esophagus,
stomach, Uver, gall biadder, pancreas or
int&inal tract not listed in Items 29-31?

Yes No

@ @
NO

0 0

0 0

BE SURE YOU HAVE ANSWERED ALL
QUESTIONS AND ENTERED ALL DATES
REQUIRED BEFORE GOING ON.
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Version 3.1

35. Are you currently using:
Birth control pills
Birth control implants (such -- Norplant)
Birth control injections (suc-- -3
Depo-Provera)
An intra-uterine deviee (IUD)

33. Have you ever had:
Difficulty starting or stopping your urine
stream
An enlarged prostate
Pain or swelling in your testicle
hydrocele, spermatocele or varicocele
34. Do you have or have you had any other
genital condition or surgery not listed in
Item 33?

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If any YES in Item 35, give date
treatment began.
yes
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End of Male Only Items

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36. Have you ever had a papSsmear?
3

Uterine fibroids
Endometriosis

c'

38. Do you currently have:
Menstrual c y c k
Irregular menstrual cycles (NOT monthly)
Bleeding or spotting between menstrual

39. Are you: --Post-menopausal (NOT due to removal of*,- a
uterus, or hysterectomy)
Post-menopausal with any vaginal bleeding o r
spotting
; & & ~ i j nraplacement
e
therapy
.y!

2
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4Q. Hare you had your uterus removed
(hysterectomy)?

6

AUW@arlnaqi

,

'Ysc

?-yd;;

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Fibrocystic breast changes

'.w;y. -.
Bmak&finp;U@
l5kqwwk

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41. Do you have or have you ever had:

BE SURE YOU RAVE ANSWERED ALL
QUESTIONS AND ElYTERED ALL DATES
REQUIRED BEFORE GOING ON.

,

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42. Do you have or have you ever had any
other ~ e c o l o g i conditions
c~
or surgery
mot listed in Items 35-41?

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End of Female OnlyA Items
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.rt , i r p n _ N

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yw WQ

FEMALES: CONTINUE WITH ITEM 43.

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REMINDER: Do NOT write explanations on these pages.

49. Have you ever broken any of the follewtng
bones?

@i!m

43. Have you had four or more bladder infections yes
(cystitis) in the past year?
@
44. Have you had two or more kidney infectloas
(pyelonephrilis) in the past two years?

--

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PeMs

@

yes

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@ 0

If any YES in Item 49, give date af

iniury.
45. Have you had:
A
e q r h d ~of.Two or more e p l a d a of Iddney stones
If any YES in Item 45, give date of
most recent occurrence.

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50. Do you have or have you ever been medically treated or
had surgery for:
w g . 6 rmd%%itOdWknrb@k#Ei@&n

459

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6 @

46. Do you have or have you had any urinary,
bladder, or kidney condition or surgery not
listed in Items 43-45?

ScoU~sisgr kyphoeis
yes NO
@
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@

If any YES in Item 50, give date of
most recent treatment or surgery.

47. Do you have or have you ever had:

Eczema or psoriasis
Basal ceU tumorts)
. of the skin
A cancerous mole or o
(NOT basal cell)

.

*

,
-

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48. Do you have any other skin ceoditlon not
listed in Item 47 for which you are taking

prseer$.tlon medication or receiving
medical treatment?
51. Other than for arthritis or burrsitis, have you been
medically treated more than twice for:
Ye8-. FQQ
Chronic shoulder pain, disloWtm @r
rat&~
cuff injury
Chronic hip pain
Chronic knee pain
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Chronic ankle pain (excluding uncompiicated
ankle strains or sprains)
,@ @

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BE SURE YOU HAVE ANSUTERED ALL
Q'ZTE;S;TIQNSA N D J Q l ~ L Z . A L LDATES

REQ~~IRED
BE'o&WINGON.

52. Have you ever had:

,
y

P J ~ 1 57. Do you have or have you ever had:

Shoulder arthroscopy, ligament repair,
reconstruction or replacement
Hip reconstruction or replacement
-.nee arthroscopy, ligament repair, B
reconstruction or replacement
Orthopedic hardware (pins, plates, rods,
screws, etc.) left in place

Fibromyalgia
Ankylosing spondylitis
Rheumatoid arthritis
Juvenile rheumatoid arthritis
Reiter's Syndrome (either single or ml
episodes)

u
@ a

58. Do you currently have:
Iron deficiency anemia
A folate deficiency
A Vitamin B-12 de
anemia)
A low platelet count (thrombocyto ia)
A missing spleen (due to surgery)
Hemochromatosis
Sickle cell disease, witn symptoms
Thalassemia disease, with symptoms
A clotting disorder
Polycythemia vera
Systemic lupus erythematosis @LE)

If any YES in Item 52, give date of
most recent surgery.

53. Do you have arthritis or bursitis that

requires the use of prescription medication?

Yes

63
4

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@
0

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3

43 @
0

@

0

0

9

0 0
@

Yes No
@

59. Do you have any other blood, immune

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system, connective tissue or collagen
condition not listed in Items 57-58?
54. Do you have or have you ever had:
Repetitive motian fnjuryI~yndrome
Carpal tunnel syndrome

60. Do you h a w dlabtes?

Yes No

0 @

Yes No

O Q
55. Do you currently have painful bunions?

Yes No
@

0

61. Do you have geut?

Yes No

0 0

56. Do you have or have you had any other

joint, muscle or bone condition or surgery
not listed in Items 49-55?

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BE SURE YOU HAVE ANSWEWlD ALL
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PLEASED8HOTWRCWMTnfSARE.4

Version

QUESTIONS AND ENTERED ALL DATES
REQIJIRED BEFORE GOING ON.

--

62. Do you have or have you ever had:
A tlij~oidgoiter
/,

L thyroid nodule
Ln overactive thyroid(hyperthyroidism)
An underactive thyroid (hypothyroidism
Other thyroid &eaw

Yes No

69. Other than a cold or the flu, do you currently Yes No
W&ctious or parasitic
0 0
condition not listed in Items 65-68?

~ ~ - - c ~ @ #have any other

0 0

@ @
70.

Do you have severe or migraine headaches
that require prescription medication?

y~

@ 0

If any YES in Item 62, give date of
most recent treatment.

71. Have you ever had any seizures or

convulsions?

Yes No

0 0

IfYES, did they occur prior to age 5, and
were they associated with high fever?
72. Have you ever had a stroke or stroke-like

symptoms?
73. Do you have;

;chw
F*- Multiple Sclerosis
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63. Do you have or have you ever had a disease
of the pituitary gland?

yes Na

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;L&.<, ; '.+--$ 1-.g-:

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0 '3

64. Do you have or have you had any other
condition of the endocrine system not listed
in I t e m M 3 ?

Yes No

65. Did you ever have a blood transfusion
before July 1992?

Yes No

66. Have you ever been exposed to Hepatitis C
virus 0
by injury, accidental
needlestick, injection of drugs (even once),
or became yeur metber had Hepatitis C
virus when you w m born?

y , ~

@

@

0 0

0 43

74. Do yon have or have you had any other
neurological or nervous system condition or
surgery not listed in Items 70-73?

Yes No

75. Do you have or have you ever had:
'j'
.-3
Idmhmia or lymph@m
Any other type of cancer or malignant
tumor not previously noted an this form

Yrr h o

@

@

0
@

@

If any YES in Item 75, give date of
most recent occurrence or treatment.

67. Do you have or have-you ever had (this does NOT refer
b immunizations):
whw5

--

3
h
Y
w

Hepati* B virus

Y u No

--

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@ 0

~ a A - J m a a FWW-=

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68. Do you have or have you ever had:
Chronic f8eylb&opg@
A wsiltive skin test far tuberculosis

Yes No

3 @

76. Are you recovering from alcohol abuse or
substance abuse?

Yes No

$r

0

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BE SURE YOU HAVE ANSWERED ALL

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Venion 3.1

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77. Have you ever had:
Family counselin
as related
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marital issues]
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Support group counseling (such as for griet
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or divorce)
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80. Have you ever received in-patient

psychiatric care?

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@

81. Have you ever tried to harm yourself

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or attempted suicide?

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78. Other than for academic guidance counseling only,
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have you ever had:
Irk#

Yes No

0 0
Yes No

0 0

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Yes No

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psychiaHst, psychologist -- mental
health ~ounselor
Substance abuse or alcohol abuse
counseling (other than awareness
counseling or classes related to traffic
citations)

treated for m eating disorder?

0 0

If YES, give date of your most recent
treatment or support group
participation.

Q @

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If any YES in Item 78, give date of last
counseling session. (NOTE:Failure to
provide date, if counseled, will delay
processing of your application.)

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%3.Do you have e r have you had any other
mental health condition not listed in
Items 76-82?

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79. Have you ever used medication(s) for a mental yes
health issue?
0

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If YES, give date of most recent use of
medication.

m, @

NO

@

;BB.

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Yes No

Does walking 2 blocks on flat terrain cause
you to experience shortness of breath, leg,
joint, muscle or chest pain?

85. Does climbing 2 flights of stairs while
carrying groceries or other items cause you
to experience shortness of breath, leg, joint,
muscle or chest pain?

Yes No

@ @

REMINDER: Do NOT write explanations on these panes.

86. Dbes heeling, squatting or sitting
cross-legged cause you 1% muscle or j&t
pain to the p i n t that you cannot do tfrese
aeth*ftles?

Yes No

87. Do you w e a prosthesis or other assisthe
device, e.g9 wheelchair, wdkwpcane, leg
braces, hearing aid(@?

Yes No

88. Do you have any deffeit in yoar hawing,
vision or speech thak might a3fed yaur
ability to learn a for&asssg~?

Yes No

89. Do you require essistPncewith routiae
activities such as walking*dressing, bathiag,
shopping or cooking?

Yes No

90. Does anything prohibit yoa from Iving and
working in very hot, cold, h
d or dry
climates, or in polluted environments?
(TI& refers to your ability to work and Ive
in these environments, NOT your pmmnnl
preferences.)

yes

91.

ye8

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pa&?ll

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0 0

0 0

DOH anything prohibit you from Uviag a i d
working at high altitudes, sueh at above
5000 feet?

92. Have you had treatment for periodontal
disease which would q u i r e therapy (net
just cleaning) more tham once per year?

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@

@

0 0

NO

0 0
Yes No

0 0

BE SURE YOU HAVE ANSWERED ALL
QUESTIONS AND ENTERED ALL DATES
REQUIRED BEFORE GOING ON.
I certify that. all of the above i n f o ~ t i o nIs true and
complete. I understand that givhgfabe or
incompkte information will delay processing my
application and may result in withdrawal of my
Peace Corps nomiaation or invitation or in
separatien from Peace Corps Service.

Printed Name

Date

Signature
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