DS-3026 Medical History and Physical Examination Worksheet

U.S. Department of State

MEDICAL HISTORY AND PHYSICAL EXAMINATION WORKSHEET
For use with DS-2053 or DS-2054
Name (Last, First, MI)

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

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 impairment 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

Multibacillary
Treated

Yes

Paucibacillary
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 addiction 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
xx-xxxx

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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 (Exception: For TB medications, use Part 4 of DS-2053 or DS-2054 form)

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 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
CONFIDENTIALITY STATEMENT
AUTHORITIES The information asked for on this form is requested pursuant to Section 212(a) and 221(d) and as
required by Section 222 of the Immigration and Nationality Act. Section 222(f) provides that the records of the
Department of States and of diplomatic and consular offices of the United States pertaining to the issuance and
refusal of visas or permits to enter the United States shall be considered confidential and shall be used only for the
formulation, amendment, administration, or enforcement of the immigration, nationality, and other laws of the United
States. Certified copies of such records may be made available to a court provided the court certifies that the
information contained in such records is needed in a case pending before the court.
PURPOSE The U.S. Department of State uses the facts you provide on this form primarily to determine your
classification and eligibility for a U.S. immigrant visa. Individuals who fail to submit this form or who do not provide all
the requested information may be denied a U.S. immigrant visa. Although furnishing this information is voluntary,
failure to provide this information may delay or prevent the processing of your case.
ROUTINE USES If you are issued an immigrant visa and are subsequently admitted to the United States as an
immigrant, the Department of Homeland Security will use the information on this form to issue you a Permanent
Resident Card, and, if you so indicate, the Social Security Administration will use the information to issue a social
security number. The information provided may also be released to federal agencies for law enforcement,
counterterrorism and homeland security purposes; to Congress and courts within their sphere of jurisdiction; and to
other federal agencies who may need the information to administer or enforce U.S. laws.

DS-3026

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