Form DS-1843 Medical History and Examination For Foreign Service For

U.S. Department of State
Office of Medical Services, Room L101, SA-1, Washington, DC 20522-0102

MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE

*OMB APPROVAL NO. 1405-0068
EXPIRATION DATE: xx-xx-xxxx
ESTIMATED BURDEN: 1 HOUR

FOR INDIVIDUALS AGE 12 AND OLDER
PRIVACY ACT NOTICE: This information is requested pursuant to the Foreign Service Act of 1980, as amended (22 U.S.C. 3084, 3901 and 3984).
The primary purpose for soliciting this information is to make appropriate assignments abroad. Unless otherwise protected by medical privacy
regulations, the information solicited on this form may be made available to appropriate agencies, whether federal, state, local or foreign, for law
enforcement and administration purposes. It may also be disclosed pursuant to court order. Failure to provide this information may result in denial of a
medical clearance and affect your Foreign Service eligibility.
Date (mm-dd-yyyy)

I. To Be Filled Out By Examinee (complete all sections, type or in ink).
1. Name of Examinee (Last, First, MI.)

2. Full Name of Employee/Applicant/Sponsor

3. Social Security Number (Employee/Applicant/Sponsor)

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

5. Sex
Male

6. Place of Birth

Female

7. Status
State

City

Country

8. Name of your Health Insurance Plan

Applicant

Spouse

Son

Other

Daughter

10a. Agency of Employee/Applicant/Sponsor
State

9. Purpose of Exam

USAID

Other

Contractor

Civil Service
Excursion Tour

10b. Type of Employment

Pre-employment

Separation

In Service

11. Mailing Address
(Medical Clearance Abstract will be mailed to listed address)

Foreign Service

12. Post of Assignment and Dates of Departure/Arrival
a. Proposed Post
EDA
(mm-dd-yyyy)
b. Present Post

Telephone Number
(where you can be
reached for the next
90 days)

EDD
(mm-dd-yyyy)
c. Last 3 Posts

E-mail Address
(where you can be
reached for the next
90 days)

13. Check and Describe Medical Conditions of Blood Relatives. Include Cancer, Alcoholism, Diabetes, Heart or Kidney Disease, High Blood
Pressure, Mental Health Disorder, or Learning Disabilities.
Father
Mother
Grandmother(s)
Grandfather(s)
Sister(s)
Brother(s)
Aunt(s)
Uncle(s)
14. Marital Status
Clearance Action

DS-1843
xx-xxxx

Married

Never Married

Other

15. Are You Adopted?

Yes

No

DO NOT WRITE IN THE SPACE BELOW (FOR USE BY MEDICAL DIVISION ONLY)

*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 recommendations for reducing it, please send them to: A/ISS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC
20522-2202.

Page 1 of 4

II. Have You Had In The Past 10 Years:

Name of Examinee:

Yes No

Yes No
1. Frequent or severe headaches?
2. Dizzy spells, fainting, or seizures?

20. Rheumatologic-problems; tendon, joint or back
pain/injury; bone-deformity or fracture?

3. Neurological disorders?

21. Malaria or other tropical disease?

4. Chronic eye trouble, or vision problems?

22. Any hair, nail or skin problems or disorders?
23. Diabetes; thyroid or other hormonal/metabolic
disease?

Date of last eye exam:
5. Tooth or gum problems?
6. Ear, nose, or throat problems, including
hearing difficulties, hoarseness, or allergies?

24. Anemia or blood transfusion?
25. Have you ever had an organ transplant or been an
organ donor?

7. Cough, wheezing, shortness of breath or asthma?

26. Recent gain or loss of 10 lbs or more?

8. Abnormal chest X-ray
9. History of positive TB skin test or clinical
tuberculosis, TB exposure, or BCG vaccination?

27. Thickening or lump in breast, testicle or elsewhere?
28. Felt unusually depressed, sad, blue or had
frequent crying spells?

10. Palpitations, chest pressure, murmurs or any
other heart problems?

29. Difficulty in relaxing or calming down; felt panicky,
irritable, angry, hyper or nervous?

11. History of aneurysm or blood clots?

30. Special education needs?

12. High blood pressure or hypercholesterolemia?

31. Have you ever used tobacco products?

13. Esophagus, stomach, intestinal, rectal, liver, or
gallbladder problems?

32. Have you ever used alcohol?
33. Have you used marijuana, hallucinogenic drugs,
narcotics, or cocaine in the last 10 years?

14. Hernia?
15. Have you had a colonoscopy or sigmoidoscopy?
Date

34. Have you ever been referred to or received mental
health treatment?
35. Do you practice safe sex?

16. A change in urinary habits, urinary tract infection
or stones, blood or protein in urine?

36. Are you at risk for AIDS?

17. Sexually-transmitted disease?

37. Do you exercise?

18. Serious infection?

38. Are you careful with your diet?

19. Cancer of any type?

39. Do you have a living will?
40. Other?

Women Only

43. Have you ever had a mammogram?

41. Do you have menstrual cycles?
Date of last menstural period

44. Have you ever had breast implants?
45. Are you pregnant?

42. Have you had an abnormal PAP test in the last
5 years?
Date of last PAP test

46. Are you nursing?
Pregnancy History: (number of times)

Date of abnormal PAP test

Pregnant

Result

Premature births

Miscarriages

Abortions
III. Hospitalizations/Operations/Medical Evacuations (Include All Medical and Psychiatric Illnesses)
Date (mm-dd-yyyy)

Illness or Operation

Name of Hospital

Live births
Living children
City and State

Please Recheck All Items for Completeness and Accuracy. DO NOT INDICATE: "Previously Answered."
IV. Explanations required for "yes"answers to questions 40 to 43 and 47 to 51. Attach additional sheet.
The intentional omission of any crucial medical information is a criminal offense (Section 1001 of the U.S.C. Title 18). Pre-employment applicants who
intentionally omit information which would make them ineligible for appointment, will be subject to disciplinary action, including separation for cause if
they are hired. Current employees may also be subject to disciplinary action for intentional omission of information.
Signature of Examinee (I certify I have read and understand the above statements).

Date (mm-dd-yyyy)

V. Examiner Comments on Significant History and Examination Findings: Comment on all items checked YES in section II.

DS-1843

Page 2 of 4

VI. To Be Completed By The Examiner
2. Height
1. Race (check one)
(needed for genetic risk factors)
White

Black

Other (specify)
VII. Clinical Evaluation

Name Of Examinee:
3. Weight
4. Pulse
in. or

lbs. or

cm.

kgs.

Check each item as indicated. Check "NE" if not evaluated.

Normal Abnormal

5. Blood Pressure (sitting) If above 140/85 repeat 3
times and record. If consistently elevated
consider treatment.

NE

Notes
(Describe Every Abnormality in Detail.
Pertinent Item Number Before Each Comment)

1. General/Constitution
2. Skin
3. Eyes
4. Ears/Nose/Throat
5. Neck/Thyroid
6. Lungs/Thorax
7. Breasts
8. Cardiovascular
9. Abdomen
10. Male Genitalia
11. Anus/Rectum/Prostate
12. Musculoskeletal
13. Lymphatic
14. Neurological
15. Female Gynecologic
16. Micellaneous
17. Papanicolaou done

Not done

Reason if not done

18. Attach cytology report.
VIII. List Current Medications (Include prescription, over the counter, vitamins, and herbals)

Drug Or Other Allergies

IX. Instructions
Disposition of Records:
All reports must be in English and identified with the full name and date of birth of the examinee.
Do Not Submit Reports by US Mail.
Do Not Submit Reports by Professional Courier Service (e.g. FedEx or DHL).
Keep originals as a permanent record.
For U.S. Department of State Health Units:
The preferred method to submit the DS-1843 is by way of eForms to Medical Records. If this is not possible, please submit the completed
document by FAX.
For Private Health Care Providers:
Please FAX the completed DS-1843 directly to Medical Records.

Department of State, Medical Records:
FAX: (703) 875-5414 or (703) 875-4850

Please confirm the report was received by sending an e-mail to [email protected]

DS-1843

Page 3 of 4

X. All Tests Required Unless Otherwise Specified. Please Attach All Reports.

Name of Examinee:

1. Hematology

7. Urinalysis (pre-employment, separation and when indicated)

Differential

Hematocrit

%

or

Granulocytes

%
%

Hemoglobin

gms%

Lymphocytes

WBC

/cmm

Eosinophils

%

Other

%

2. Screening Chemistry (pre-employment and at least every 5 years)
Blood Sugar

Creatinine

Cholesterol

ALT

HDL/LDL

GGT

Triglycerides

HbA1C (when indicated)

3. Serology (specify test and results) (12 years and over for
pre-employment and approx. every 5 years after)
RPR/VDRL
HIV I/II antibody

Specific
Gravity

WBC

Albumin

RBC

Sugar

Casts

8. ECG (50 years or earlier when indicated. All pre-employment 40
years and above. Submit all tracings).
Results
9. Chest X-Ray (required for persons 18 years and over for
pre-employment and separation, for new TB skin test converters or
when indicated. If pregnant, baseline chest X-ray required after
delivery)
Date (mm-dd-yyyy)

Results

10. Tuberculin Test (5TU PPD)
(recommended for all examinees including
those with previous BCG)
Date (mm-dd-yyyy)

HepB surface antigen

If Not Done, Explain

HepC antibody

Results:

4. Stool Exam for Occult Blood
(50 years or earlier when
indicated)
a. Pos

Neg

b. Pos

Neg

c. Pos

Neg

5. Colon Screen
(age 50 or when indicated by
risk factors according to
current standards of care)
FFS, Barium Enema, or
Colonoscopy.
Attach most recent results.

Previous Positive

mm of Induration

11. Pre-employment
and in Service if
not previously
done. (not for
separation)
a. Blood Type
ABO

Yes

No

(Rh) D

Previous Rx Complete Yes

No

(weak) D

u

Date Completed (mm-dd-yyyy)
New Converter Yes
(X-Ray required)
Treatment

No

b. G6PD
Normal
Deficient

6. PSA (50 years or earlier when indicated.)

12. Mammogram (required age 50 years and over, recommended age
40 and over)

XI. Assessment Or Problem List

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

Typed Name of Examiner

Signature

Examining Facility

Address

Date (mm-dd-yyyy)

Telephone Number
Fax Number
DS-1843

Page 4 of 4