DS-3026 Medical History and Physical Examination Worksheet

U.S. Department of State

OMB No. 1405-0113
EXPIRATION DATE: xx/xx/xxxx
ESTIMATED BURDEN: 35 minutes
(See Page 2 - Back of Form)

MEDICAL HISTORY AND PHYSICAL EXAMINATION WORKSHEET
For use with DS-2053
Name (Last, First, MI)

Exam Date (mm-dd-yyyy)
Alien (Case) Number

Passport Number

Birth Date (mm-dd-yyyy)

1. Past Medical History (indicate conditions requiring medication or other treatment after resettlement and give details in Remarks)
NOTE: The following history has been reported, has not been verified by a physician, and should not be deemed medically definitive.
No Yes
No Yes
General
Ever caused SERIOUS injury to others, caused MAJOR
Illness or injury requiring hospitalization (including psychiatric)
property damage or had trouble with the law because of
medical condition, mental disorder, or influence of alcohol or
Cardiology
drugs
Angina pectoris
Obstetrics
and Sexually Transmitted Diseases
Hypertension (high blood pressure)
Pregnancy
Fundal height
cm
Cardiac arrhythmia
Last menstrual period Date (mm-dd-yyyy)
Congenital heart disease
Sexually transmitted diseases, specify
Pulmonology
History of tobacco use
Current use
Asthma

Yes

Endocrinology and Hematology

No

Diabetes mellitus

Chronic obstructive pulmonary disease (emphysema)

Thyroid disease

History of tuberculosis (TB) disease
Treated
Yes
No

History of malaria

Current TB symptoms
Neurology and Psychiatry

Yes

Other
Malignancy, specify

No

Chronic renal disease

History of stroke, with current impairment

Chronic hepatitis or other chronic liver disease

Seizure disorder

Hansen's Disease

Major impairement in learning, intelligence, self care, memory, or
communication
Major mental disorder (including major depression, bipolar disorder,
schizophrenia, mental retardation)
Use of drugs other than those required for medical reasons

OR

Tuberculoid

Borderline

Paucibacillary
Treated

Lepromatous

Multibacillary

Yes

No

Visible disabilities (including loss of arms or legs),
specify

Addiction or abuse of specific* substance (drug)
*amphetamines, cannabis, cocaine, hallucinogens, inhalants,
opioids, phencyclidines, sedative-hypnotics, and anxiolytics
Other substance-related disorders (including alcohol addiciton or
abuse)

Other requiring treatment, specify

Ever taken action to end your life
2. Physical Examination (indicate findings and give details in Remarks)
No

cm

Height
/

BP

Applicant appears to be providing unreliable or false information, specify

Yes

(mmHg)

kg

Weight
Heart rate

/min
*N, normal;

N*

A*

Visual Acuity at 20 feet: Uncorrected L 20/

Respiratory rate

/min

Corrected L 20/

R 20/
R 20/

A, abnormal; ND, not done
N*

ND*

A*

ND*

General appearance and nutritional status

Inguinal region (including adenopathy)

Hearing and ears

Extremities (including pulses, edema)

Eyes

Musculoskeletal system (including gait)

Nose, mouth, and throat (include dental)

Skin (including hypopigmentation, anesthesia,
consistent with self-inflicted injury or injections)

Heart (S1, S2, murmur, rub)
Breast
Lungs
Abdomen (including liver, spleen)

findings

Lymph nodes
Nervous system (including nerve enlargement)
Mental status (including mood, intelligence, perception,
thought processes, and behavior during examination)

Genitalia (including circumcision, infection(s))
DS-3026

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3. Additional Testing Needed Prior to Approving Medical Clearance
No Yes
Physical examination or laboratory results contradict medical history
Referral prior to departure If yes, provide results

Referral prior to departure If yes, provide results

4. Follow-up Needed After Arrival
No

Yes, within 1 week

Yes, within 1 month

Yes, within 6 months

For continuing medication, list type, dose, and frequency

For continuing other treatment, specify

5. Remarks (describe any abnormal history, abnormal findings, and resulting interventions)

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
Public reporting burden for this collection of information is estimated to average 35 minutes per response,
including time required for searching existing data sources, gathering the necessary data, providing the
information required, and reviewing the final collection. Persons are not required to provide this information in the
absence of a valid OMB approval number. Send comments on the accuracy of this estimate of the burden and
recommendations for reducing it to: the U.S. Department of State (A/ISS/DIR) Washington, DC 20520.

AUTHORITIES The information is sought pursuant to Sections 212(a), 221(d), 101, and 412(b)(4) and (5) of the
Immigration and Nationality Act.
PURPOSE The primary purpose for soliciting medical information is to determine whether an applicant is eligible
to obtain a visa and alien registration. This form is designed to record the result of the medical examination
required by INA 221(d), which determines whether an applicant has a medical condition that renders the
applicant ineligible under INA Section 212(a).
ROUTINE USES The information solicited on this form may be made available to the U.S. Department of
Homeland Security for disclosure to the Centers for Disease Control and Prevention and to the U.S. Public
Health Service. The information provided also may be released to federal agencies for law enforcement,
counter-terrorism and homeland security purposes; to Congress and courts within their sphere of jurisdiction;
and to other federal agencies for certain personnel and records management matters.
Although furnishing this information is voluntary, failure to provide this information may delay or prevent the
processing of your case.

DS-3026

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