Main Medical Form Medical Examination for Immigrant or Refugee Applicant (

MEDICAL EXAMINATION FOR
IMMIGRANT OR REFUGEE APPLICANT

For Use in Canada Only
Name (Last, First, MI.)

Photo

,

,

Birth Date (mm-dd-yyyy)

Sex:

Birthplace (City/Country)

M

F

/
Prior Country

Present Country of Residence
U.S. Consul (City/Country)
Passport Number

/
Alien (Case) Number
Date (mm-dd-yyyy) of Prior Exam, if any

Date (mm-dd-yyyy) of Medical Exam

Date Exam Expires (6 months from examination date, if Class A or TB condition exists, otherwise 12 months) (mm-dd-yyyy)
Exam Place (City/Country)

Panel Physician

/

Radiology Services

Screening Site (name)

Lab (name for syphilis/TB)

/

/

(1) Classification (check all boxes that apply):
No apparent defect, disease, or disability (see Worksheets 1,2, and 3)
Class A Conditions (From Past Medical History and Physical Examination Worksheets)
TB, active, infectious (Class A, from Chest X-Ray Worksheet)

Hansen's disease, lepromatous or multibacillary

Syphilis, untreated

Addiction or abuse of specific* substance without harmful
behavior
Any physical or mental disorder (including other
substance-related disorder) with harmful behavior or history of
such behavior likely to recur

Chancroid, untreated
Gonorrhea, untreated
Granuloma inguinale, untreated

*amphetamines, cannabis, cocaine, hallucinogens, inhalants,
opioids, phencyclidines, sedative-hypnotics, and anxiolytics

Lymphogranuloma venereum, untreated

Class B Conditions (From Past Medical History and Physical Examination Worksheets)
TB, active, noninfectious (Class B1, from Chest X-Ray Worksheet)
Treatment:

None

Partial

Completed

TB, inactive (Class B2, from Chest X-Ray Worksheet)
Treatment:

None

Partial

Completed

See Section 4 on page 2 for TB treatment details
Syphilis (with residual deficit), treated within the last year
Other sexually transmitted infections, treated within last year
Current pregnancy, number of weeks pregnant

Hansen's disease, prior treatment
Hansen's disease, tuberculoid, borderline, or paucibacillary
Sustained, full remission of addiction or abuse of specific*
substances
Any physical or mental disorder (excluding addiction or abuse of
specific* substance but including other substance-related
disorder) without harmful behavior or history of such behavior
unlikely to recur
*amphetamines, cannabis, cocaine, hallucinogens, inhalants,
opioids, phencyclidines, sedative-hypnotics, and anxiolytics

Other (specify or give details on checked conditions from worksheets)

(2) Laboratory Findings (check all boxes that apply):
Syphilis:
Not done
Test name

Date(s) run (mm-dd-yyyy)

Negative

Positive

Titer 1

Notes

Screening
Confirmatory
Treated
Yes
No

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If treated, therapy:

Date(s) treatment given (3 doses for penicillin)

Benzathine penicillin, 2.4 MU IM
Other (therapy, dose):E

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(3) Immunizations (See Vaccination Form, check all boxes that apply) Not required for refugee applicants.
Vaccine history incomplete, requesting waiver (indicate type below)

Vaccine history complete

Blanket waiver

Incomplete vaccine history, no waiver requested

Individual waiver

I certify that I understand the purpose of the medical examination and I authorize the required tests to be completed.

Applicant Signature

Panel Physician Signature

Date (mm-dd-yyyy)

(4) Tuberculosis Treatment Regimen
(Fill out if applicant has taken in the past, or is now taking TB medication. If drug doses or dates not
known or not available, mark "unknown".)
Check if therapy currently prescribed (if current, don't mark "End Date")

Medication

Dose/Interval
(i.e., mg/day)

Start Date
(mm-dd-yyyy)

End Date
(mm-dd-yyyy)

Isonaizid (INH)
Rifampin
Pyrazinamide
Ethambutol
Streptomycin
Other, specify

Applicant's weight (kg)
Remarks

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