Table of Changes

TABLE OF CHANGES – FORM

FORM I-693

Submission Date: April 27, 2011

LOCATION	CURRENT VERSION	PROPOSED VERSION
I-693, page 1, part 1 title	Part 1. Information About You (The person requesting a medical examination or vaccinations must complete this part)	Part 1. Information About You (To be completed by the person requesting a medical examination, not the civil surgeon)
I-693, page 1, part 1	[Applicant’s Certification signature fields]	[Add a text field next to signature box, entitled “To be completed by civil surgeon: Form of applicant ID presented (e.g., passport, driver’s license)”]. Near that new box, add text field, entitled “ID Number (if any)”]
I-693, page 1, part 2 title	Part 2. Medical Examination (The civil surgeon completes this part)	Part 2. Summary of Medical Examination (To be completed by the civil surgeon)
I-693, page 1, part 2 (Medical Examination)	1. Examination	[delete]
	[Boxes for Dates of Medical Exams are above the Summary of Overall Findings]	[Move boxes for Dates of Medical Exams below the Summary of Overall Findings]
	[Check boxes for Summary of Overall Findings: __ No Class A or Class B Condition __ Class A Conditions (see 2 through 5 below) __ Class B Conditions (see 2 through 6 below)]	[Revise accordingly: __Class A Conditions (see Civil Surgeon Worksheet, sections 1-3) __Class B Conditions (see Civil Surgeon Worksheet, sections 1-4) Also, line up the above two check boxes so the remaining check box stands out to the left]
I-693, page 1, part 2.2	[Section: 2. Communicable Diseases of Public Health Significance]	[Replace this section on page 1 with “Part 3. Civil Surgeon’s Certification” – use title language from Part 5 of the current I-693, on top of page 6]
	[From current I-693, in Part 5:] I certify under penalty of perjury under United States law that: I am a civil surgeon in current status designated to examine applicants seeking certain immigration benefits in the United States; I have a currently valid and unrestricted license to practice medicine in the state where I am performing medical examinations; I performed this examination of the person identified in Part 1 of this Form I-693, after having made every reasonable effort to verify that person whom I examined is the person identified in Part 1; that I performed the examination in accordance with the Centers for Disease Control and Prevention’s Technical Instructions, and all supplemental information or updates; and that all information provided by me on this form is true and correct to the best of my knowledge, and belief.	I certify under penalty of perjury under United States law that: I am a civil surgeon designated to examine applicants seeking certain immigration benefits in the U.S. OR a physician who qualifies under a blanket designation specified by policy or law; I have a currently valid and unrestricted license to practice medicine in the state where I am performing medical examinations unless exempted from this requirement; I performed this examination of the person identified in Part 1 of this Form I-693, after having made every reasonable effort to verify that the person whom I examined is in fact the person identified in Part 1; that I performed the examination in accordance with the Centers for Disease Control and Prevention’s Technical Instructions, and all supplemental information or updates; and that all information provided by me on this form is true and correct to the best of my knowledge, and belief. [Also make this font size smaller, to match the applicant’s certification in Part 1]
	[From current I-693, in Part 5 – data fields for civil surgeon’s identifying information]	[1. Shorten the text field for “Name of Medical Practice or Health Department” to same length as the above “Address” field 2. Edit text “Daytime Phone # (Include Area Code) no dashes or ( )” to read “E-Mail/Daytime Phone # (Include Area Code) no dashes or ( )” 3. Delete “E-Mail Address” and its text field 4. Move “Signature” and “Date” and their text fields down, so they are immediately to the right of “Name of Medical Practice” and “Daytime Phone #” 5. In the new space to the right of “Type or Print Full Name” and “Address,” insert the text “(For Health Departments Only: Place official stamp or seal here)” – center this new text vertically and horizontally in the empty space.]
I-693, page 2	N/A	[At top of page, add text fields for “Name of Applicant” and “A-Number (if any)”]
	N/A	[Insert new title at top of page 2: “Civil Surgeon Worksheet”]
	N/A	[Insert text under title: “ (To be completed by the civil surgeon, according to the Technical Instructions at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html)”]
	Part 2. Communicable Diseases of Public Health Significance (Cont’d)	1. Communicable Diseases of Public Health Significance [Move beginning of Part 2.2A from bottom of page 1 of current I-693 to top of page 2 so that the entire section A is on page 2]
	[From Part 2.2A on page 1 of current I-693:] An initial screening test, either a Tuberculin Skin Test (TST) or an Interferon Gamma Release Assay (IGRA) is required for all applicants 2 years of age and older; for children under 2 years of age, see Technical Instructions at http://cdc.gov/ncidod/dq/civil.htm. The civil surgeon should perform one type of initial screening test only, followed by further evaluation, if needed (chest X-ray).	An initial screening test, either a Tuberculin Skin Test (TST) or an Interferon Gamma Release Assay (IGRA) is required for all applicants 2 years of age and older; for children under 2 years of age, see Technical Instructions. The civil surgeon should perform one type of initial screening test only, followed by further evaluation, if needed (chest X-ray). Delete parts
I-693, page 2	[From Part 2.2A on page 1 of current I-693 under Tuberculin Skin Test section:] “Not administered (TST exception applies)”	Not administered (TST exception applies; please explain in Remarks section below)
	[From Part 2.2A on page 1 of current I-693 under Interferon Gamma Release Assay section:] 2. Interferon Gamma Release Assay (IGRA) (for acceptable IGRAs consult the Technical Instructions and any updates posted on CDC’s Web site at http://www.cdc.gov/ncidod/dq/civil.htm): Not administered (IGRA exception applies)	2. Interferon Gamma Release Assay (IGRA) (for acceptable IGRAs consult the Technical Instructions and any updates posted on CDC’s Web site): Not administered (IGRA exception applies; please explain in Remarks section below) [Also, please make font size the same size as TST exception text referenced above]
	[In current I-693, Part 2.2A is split on pages 1-2]	[Once Part 2.2A is combined onto one page, please reconfigure boxes in IGRA section so it mirrors the TST section above it, for instance: Check box with text “Not administered” placed first on top Three long boxes for test details placed under check box, lined up in a row Under that, “Result:” and two check boxes lined up in a row for “Negative” and “Positive”]
	[In Part 2.2A on page 2 of current Form I-693 under Initial Screening Test Result section:]	[1. Add the number “3” to this section heading. 2. Rearrange the checkboxes in this section to line up in a row. 3. Revise the parenthetical for the last checkbox to read:] (The civil surgeon must clearly specify the TST or IGRA exception in the Remarks section below)
	Remarks: (Include any signs or symptoms of TB, additional tests, and therapy given, with stop and start dates and any changes.)	Remarks: (If needed, include any signs or symptoms of TB, additional tests, and therapy given, with stop and start dates and any changes. If tests were not administered, give reason why exception applies) [Also, make font size larger to match the other numbered headings above.]
	[Remarks box]	[Make Remarks box much smaller, as needed to fit Part 2.2A onto one page]
I-693, page 3	N/A	[At top of page, add text fields for “Name of Applicant” and “A-Number (if any)”]
	Part 2. Medical Examination (Continued)	Civil Surgeon Worksheet (Continued)
	3. Physical or Mental Disorders With Associated Harmful Behaviors	2. Physical or Mental Disorders With Associated Harmful Behaviors
	4. Drug Abuse/Drug Addiction **(“Drug Abuse/Drug Addiction” addresses non-medical use only with respect to substances listed in Schedule I, II, III, IV, or V under Section 202 of the Controlled Substances Act. Include here any diagnosis of substance abuse/dependence based on DSM criteria for a substance listed in Schedule I, II, III, IV, or V of Section 202 of the Controlled Substances Act. See CDC’s Technical Instructions posted on CDC’s Web site at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html.)	3. Drug Abuse/Drug Addiction **(“Drug Abuse/Drug Addiction” addresses non-medical use only with respect to substances listed in Schedule I, II, III, IV, or V under Section 202 of the Controlled Substances Act. Include here any diagnosis of substance abuse/dependence based on DSM criteria for a substance listed in Schedule I, II, III, IV, or V of Section 202 of the Controlled Substances Act. See CDC’s Technical Instructions for more information.) Delete parts
I-693, page 4	N/A	[At top of page, add text fields for “Name of Applicant” and “A-Number (if any)”]
	[vaccination chart]	[Move entire page 4 of current I-693 to page 5]
	Part 2. Medical Examination (Continued)	Civil Surgeon Worksheet (Continued)
I-693, page 4 (taken from current page 5)	6. List other medical conditions, Class B other (e.g., hypertension, diabetes)	4. Other Medical Conditions (List any other Class B conditions, e.g., hypertension, diabetes.)
I-693, page 4 (taken from current page 5), part 3	Part 3. Referral to Health Department Other Doctor/Facility (To be completed by the civil surgeon, if referral was required and made)	Part 3. 5. Referral to Health Department or Other Doctor (To be completed by civil surgeon if referral was medically required)
I-693, page 4 (taken from current page 5), part 4	Part 4. To Be Completed by Physician or Health Department Performing Referral Evaluation The applicant identified on this form was referred to me by the civil surgeon named in Part 5 of this form. . . .	Part 4. 6. Referral Evaluation (To be completed by the health department or other doctor performing the referral evaluation) The applicant identified on this form was referred to me by the civil surgeon named in Part 3 of this form. . . .
I-693, page 5	N/A	[At top of page, add text fields for “Name of Applicant” and “A-Number (if any)”]
	Part 2. Medical Examination (Continued)	Vaccination Record [centered in header] and underneath: “(See Technical Instructions at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/vaccination-civil-technical-instructions.html for list of required vaccines)
I-693, page 5 (taken from current page 4)	5. Vaccinations (See Technical Instructions at http://www.cdc.gov/ncidod/dq/civil.htm for list of required vaccines)	Please make sure every row is marked. Reserve all comments for the Remarks section below. Note: For purposes of the influenza vaccine, the flu season is October 1 through March 31. For certain applicants who only require a vaccination assessment: You need only submit this page with Page 1 of Form I-693. See Form Instructions – FAQ section for more information.
	[Applicant name and A-number text fields on lower right side]	[Replace applicant name and A-number text fields with a set-off box that says inside: “FOR USCIS USE ONLY”; inside that box, add words “Remarks (if any):”]

TABLE OF CHANGES – INSTRUCTIONS

FORM I-693

Submission Date: April 22, 2011

LOCATION	CURRENT VERSION	PROPOSED VERSION
Form Instructions, page 1, Section I. Applicant’s Instructions	How Do I Find a Designated Civil Surgeon in the Area Where I Live? To find a designated civil surgeon in your area, you can call the USCIS National Customer Service Center (NCSC) at 1-800-375-5283 and follow the instructions in the automated menu. Service is available in English and Spanish. A list of the designated civil surgeons in your area can also be generated by going to the civil surgeon page from the USCIS Web site at www.uscis.gov and clicking on the civil surgeon locator under “Immigration Medical Examinations” in the “Services and Benefits” selection choice.	How Do I Find a Designated Civil Surgeon in the Area Where I Live? To find a designated civil surgeon in your area, you can call the USCIS National Customer Service Center (NCSC) at 1-800-375-5283 and follow the instructions in the automated menu. Service is available in English and Spanish. A list of the designated civil surgeons in your area can also be generated by going to the civil surgeon page from the USCIS Web site at www.uscis.gov and clicking on “Find a Medical Doctor (Civil Surgeon)” under Customer Tools: Before I File. the civil surgeon locator under “Immigration Medical Examinations” in the “Services and Benefits” selection choice.
Form Instructions, page 1, Section I. Applicant’s Instructions	How Do I Fill Out My Portion of Form I-693? * * * 2. You must fill out only Part 1. The civil surgeon and any other doctors, clinics, or health departments receiving a referral are required to complete Parts 2 through 6. A. * * * B. Family Name (Last Name) – Use your legal name. If you have two last names, include both and use a hyphen (-) between the names, if appropriate.	How Do I Fill Out My Portion of Form I-693? * * * 2. You must fill out only Part 1 and identifying information at the top of each page. The civil surgeon and any other doctors, clinics, or health departments receiving a referral are required to complete the remaining parts of the form. Parts 2 through 6. A. * * * B. Identifying information at top of each page – Fill out your name and A-number, if applicable, at the top of each page of Form I-693. The civil surgeon will check that this information matches Part 1. C. Family Name (Last Name) – Use your legal name. If you have two last names, include both and use a hyphen (-) between the names, if appropriate. [Re-letter list accordingly]
Form Instructions, page 2, Section II. Civil Surgeon’s Instructions	What are My Responsibilities as a Designated Civil Surgeon? 1. Truthfully and Accurately Report the Results. You are responsible for reporting the results of the medical exam and all laboratory reports on Form I-693 where indicated, and for signing the civil surgeon’s certification provided on the form. In this regard, you must take reasonable steps to ensure that the person appearing for the medical exam is the same person applying for the requested immigration benefit. All applicants must present a valid government-issued photo identification. The law imposes severe penalties for knowingly and willfully falsifying or concealing a material fact or using any false documents in connection with this medical exam.	What are My Responsibilities as a Designated Civil Surgeon? 1. Truthfully and Accurately Report the Results. You are responsible for reporting the results of the medical exam and all laboratory reports on Form I-693 where indicated, and for signing the civil surgeon’s certification provided on the form. In this regard, you must take reasonable steps to ensure that the person appearing for the medical exam is the same person applying for the requested immigration benefit. All applicants must present a valid government-issued photo identification, and the civil surgeon must annotate in Part 1the form of identification presented and ID number, if applicable. The law imposes severe penalties for knowingly and willfully falsifying or concealing a material fact or using any false documents in connection with this medical exam. The civil surgeon should also ensure that the applicant’s name and A-number, if applicable, at the top of each page of the Form I-693 matches the information provided in Part 1.
Form Instructions, page 3, Section II. “How Do I Fill Out My Portion of This Form?”	1. Part 2 – Medical Examination – You must fill out this part and provide the results of each component of the medical exam relating to: communicable disease of public health significance, vaccinations, physical or mental disorder with associated harmful behavior, and substance or drug abuse/substance or drug addiction. In Part 2, you must also include the results of any lab work or other studies required to determine whether the applicant is inadmissible on health grounds. You must instruct applicants who have had a tuberculin skin test (TST) to return to your office within 48-72 hours to have the TST read.	1. Civil Surgeon Worksheet. You must fill out this worksheet this part and provide the results of each component of the medical exam relating to: communicable diseases of public health significance, vaccinations, physical or mental disorders with associated harmful behavior, and substance or drug abuse/substance or drug addiction, and vaccinations. In Part 2, you You must also include the results of any lab work or other studies required to determine whether the applicant is inadmissible on health grounds. You must instruct applicants who have had a tuberculin skin test (TST) to return to your office within 48-72 hours to have the TST read.
	2. Part 3 – Referral to Health Department or Other Doctor/Facility. If you refer the applicant to a local health department or to another physician or clinic, you must also fill out Part 3. Also see Part 5.	2. Part 3 – Referral to Health Department or Other Doctor/Facility. If you refer the applicant to a local health department or to another physician or clinic, you must also fill out section 5 of the Civil Surgeon Worksheet in Form I-693. The health care professional receiving the referral must fill out and sign the section 6 of the Civil Surgeon Worksheet.
	3. Part 4 – Physician or Health Department Receiving the Referral. If you refer the applicant for further tests or evaluation, the health care professional receiving the referral must fill out and sign Part 4.	[delete]
	4. Part 5 – Civil Surgeon’s Certification. You must sign the certification after the initial medical exam and all referrals/follow-up examinations (if required) have been completed. Complete the identifying information in this part before referring an applicant for further tests or evaluation. Do not sign and date this part until the referral/follow-up evaluation (if required) has been completed and the applicant has been medically cleared.	3. Part 3 – Civil Surgeon’s Certification. You must sign the certification after the initial medical exam is complete and all referrals/follow-up examinations (if required) have been completed. Fill out Complete the identifying information in this part before referring an applicant for further tests or evaluation. Do not sign and date this part until the referral/follow-up evaluation (if required) has been completed and the applicant has been medically cleared. Stamped signatures are not acceptable, your signature must be original. For health departments performing the vaccination assessment for refugee adjustment applicants ONLY: You must also complete Part 3 of Form I-693. The actual (original) or stamped signature of the physician on staff at the health department must be present in Part 3. Signatures by attending nurses, physician assistants, or other medical professionals that are not licensed physicians will be rejected. Health departments must also place either the official stamp or raised seal, whichever is customarily used, in Part 3 where indicated.
	5. Part 6 – Health Department Identifying Information. If you are a State or local health department that is completing the vaccination record on behalf of a refugee, you must complete this part.	[delete]
Form Instructions, page 3, Section II. “How Do I Complete Form I-693 If I Need to Make a Referral?”	Advise the applicant that the appropriate follow-up must be obtained before medical clearance can be granted. In Part 3, include the name, address, and telephone number of the onward physician or public health service facility that will conduct further evaluation or provide treatment. Specify the type of examination and additional tests or treatment the applicant should receive. Complete the identifying information in Part 5, but do not sign or date. Make a copy of Form I-693 for your records and give the original form to the applicant in a sealed envelope.	Advise the applicant that the appropriate follow-up must be obtained before medical clearance can be granted. In section 5 of the Civil Surgeon Worksheet (Referral to Health Department or Other Doctor), include the name, address, and telephone number of the onward physician or public health service facility that will conduct further evaluation or provide treatment. Specify the type of examination and additional tests or treatment the applicant should receive. Complete your identifying information in Part 3, but do not sign or date. Make a copy of Form I-693 for your records and give the original form to the applicant in a sealed envelope.
Form Instructions, page 3, Section II. “What Do I Do After the Medical Exam and Follow-Up (If Required) Are Completed?”	You and the applicant must sign your respective certifications. After the medical exam (and any follow-up if required) is complete, write the results in Part 2 of the Form I-693 as they relate to the specific component of the medical exam. The applicant must sign the certification in Part 1, and you must sign the civil surgeon’s certification in Part 5. All signatures on the form must be originals (no stamps or facsimiles). Do not sign the form or have the applicant sign the form until the applicant has met all health follow-up requirements.	You and the applicant must sign your respective certifications. After the medical exam (and any follow-up if required) is complete, write the results in Part 2 of the Form I-693 as they relate to the specific component of the medical exam. The applicant must sign the certification in Part 1, and you must sign the civil surgeon’s certification in Part 3. All signatures on the form must be originals (no stamps or facsimiles). Do not sign the form or have the applicant sign the form until the applicant has met all health follow-up requirements.
Form Instructions, page 4, Section III. Frequently Asked Questions	1. What if I am a refugee and already had a medical exam overseas? If you were admitted to the United States as a refugee . . . found during that exam. If a complete medical exam is not required, you only need to comply with the vaccination requirements. This means you only need to complete Part 1, Information About You, and the vaccination section of Part 2, not Form I-693. Contact your State or local refugee health coordinator to find out whether it may be possible for you to have the vaccination portion of Form I-693 completed by a State or local health department. The State or local health department must also complete Part 6 of the Form.	1. What if I am a refugee and already had a medical exam overseas? If you were admitted to the United States as a refugee . . . found during that exam. If a complete medical exam is not required, you only need to comply with the vaccination requirements. This means you only need to submit the vaccination record and page 1 of Form I-693. complete Part 1, Information About You, and the vaccination section of Part 2, not Form I-693. Contact your State or local refugee health coordinator to find out whether it may be possible for you to have the vaccination portion of Form I-693 completed by a State or local health department. The State or local health department must also complete Part 3 of the form.
	2. What if I am a K nonimmigrant visa holder and already had a medical exam overseas? * * * b. Even if a new medical examination is not required, you must still show proof that you complied with the vaccination requirements. If the vaccination record (DS 3025) was not properly completed and included as part of the original, overseas medical examination report, you will have to have the vaccination report completed by a designated civil surgeon. In this case, you are required to submit Part 1, InformationAbout You, Part 2, the vaccination chart and Part 5, the Civil Surgeon’s Certification, of Form I-693.	2. What if I am a K nonimmigrant visa holder and already had a medical exam overseas? * * * C. 2. Even if a new medical examination is not required, you must still show proof that you complied with the vaccination requirements. If the vaccination record (DS 3025) was not properly completed and included as part of the original [delete comma] overseas medical examination report, you will have to have the vaccination report completed by a designated civil surgeon. In this case, you are required to submit the vaccination record and page 1 of Form I-693. Part 1, Information About You, Part 2, the vaccination chart and Part 5, the Civil Surgeon’s Certification, of Form I-693.
	3. What if I am a V nonimmigrant visa holder and already had a medical exam overseas? * * * b. Even if a new medical examination is not required, you still must show proof that you complied with the vaccination requirements. If the vaccination record was not properly completed and included as part of the original, medical examination report, you will have to have the vaccination report completed by a designated civil surgeon. In this case, you are required to complete Part 1, Information About You, Part 2, with the proper Civil Surgeon’s Certification, Part 5 of Form I-693.	3. What if I am a V nonimmigrant visa holder and already had a medical exam overseas? * * * D. 2. Even if a new medical examination is not required, you still must show proof that you complied with the vaccination requirements. If the vaccination record was not properly completed and included as part of the original [delete comma] medical examination report, you will have to have the vaccination report completed by a designated civil surgeon. In this case, you are required to submit the vaccination record and page 1 of Form I-693. complete Part 1, Information About You, Part 2, with the proper Civil Surgeon’s Certification, Part 5 of Form I-693.
Form Instructions, page 5, Section III. Frequently Asked Questions (cont’d)	[last part of item 4(B) from page 4:] You will, however, be required to comply with the vaccination requirement and complete Part 1, Information About You, and submit the vaccination section of Part 2 with your Form I-485. A designated civil surgeon must complete the vaccination section and Part 5, Civil Surgeon’s Certification.	You will, however, be required to comply with the vaccination requirement and submit the vaccination record and page 1 of Form I-693 with your Form I-485. complete Part 1, Information About You, and submit the vaccination section of Part 2 with your Form I-485. A designated civil surgeon must complete the vaccination section and Part 5, Civil Surgeon’s Certification.
	6. How do I know whether a doctor is a designated civil surgeon? You can obtain a list of the designated civil surgeons by 1-800-375-5283, visiting the civil surgeon page from the USCIS Web site at www.uscis.gov, and clicking on the “Civil Surgeon Locator” under “Immigration Medical Examinations” of the “Services and Benefits” section, or by visiting your local USCIS office. Note: If you choose to visit your local USCIS office, you must first get an InfoPass appointment. For information on InfoPass, visit the USCIS Web site at www.uscis.gov.	6. How do I know whether a doctor is a designated civil surgeon? Doctors found through the USCIS National Customer Service Center (NCSC) phone line or through the USCIS Web site are generally current in their designation as civil surgeons. If unsure, applicants should confirm with their doctors as to their civil surgeon status. You can obtain a list of the designated civil surgeons by 1-800-375-5283, visiting the civil surgeon page from the USCIS Web site at www.uscis.gov, and clicking on the “Civil Surgeon Locator” under “Immigration Medical Examinations” of the “Services and Benefits” section, or by visiting your local USCIS office. Note: If you choose to visit your local USCIS office, you must first get an InfoPass appointment. For information on InfoPass, visit the USCIS Web site at www.uscis.gov.
Form Instructions, page 5, Communicable Diseases of Public Health Significance section	The civil surgeon is required to perform specific tests for TB, syphilis. The medical exam also indicates an evaluation for other sexually transmitted diseases and Hansen’s Disease (leprosy).	The civil surgeon is required to perform specific tests for TB and syphilis. The medical exam also indicates an evaluation for other sexually transmitted diseases and Hansen’s Disease (leprosy).
Form Instructions, page 6, Table, box next to “Tuberculosis (TB)” (from current page 5)	2. IGRA: IGRAs are blood tests that are options to the TST (see update to the Technical Instructions at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/updates-civil-surgeons.html) You will not have to return to the civil surgeon’s office for the result to be read. The result is generally available within 24 hours. If the test is negative or indeterminate/borderline/equivocal, you generally will not need any further tests to TB. Depending on the result of the test, further evaluation with a chest x ray may be required.	2. IGRA: Civil surgeons have the option of using IGRA in place of the TST IGRAs are blood tests that are options to the TST (see update to the Technical Instructions at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/updates/index.html). You will not have to return to the civil surgeon’s office for the result to be read. The result is generally available within 24 hours. If the test is negative or indeterminate/borderline/equivocal, you generally will not need any further tests to TB. Depending on the result of the test, further evaluation with a chest x-ray may be required.

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