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: 04-30-2012
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. 4084, 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. The information requested is voluntary however 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. eMED Number if known (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

10. Agency of Employee/Applicant/Sponsor
Foreign Commercial
Service

State

USAID

Foreign Agricultural
Service

Board of Broadcasting Governors

9. Purpose of Exam
Separation

In Service

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

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

EDD

(mm-dd-yyyy)

c. Last 3 Posts

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. The following asks questions about family medical history. Providing this information is strictly
voluntary and will only be used for diagnosis and treatment, and only by providers in MED. Medical clearance decisions do not take into consideration
family medical history, but only manifested medical conditions. Therefore examinee is not required to answer questions 13 a-h.
a. Father
b. Mother
c. Grandmother(s)
d. Grandfather(s)
e. Sister(s)
f. Brother(s)
g. Aunt(s)
h. Uncle(s)
14. Marital Status

Married

Never Married

Other

15. Are you adopted?
Yes

No

As part of this examination, you may be asked for Family Medical History. Providing this information is strictly voluntary and will only be used for
diagnosis and treatment, and only by medical providers in MED. Medical clearance decisions do not take into account Family Medical History, but only
manifest diseases and medical conditions.

Signature
DS-1843
xx-2011

Date (mm-dd-yyyy)

*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/GIS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC
20522-2202.

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II. Have You Had In The Past 5 Years:

Name of Examinee:
Yes No

Yes No

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

1. Frequent or severe headaches?
2. Dizzy spells, fainting, or seizures?

20. Malaria or other tropical disease?

3. Neurological disorders?

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

4. Chronic eye trouble, or vision problems?
Date of last eye exam (mm-dd-yyyy)
5. Tooth or gum problems?
6. Ear, nose, or throat problems, including
hearing difficulties, hoarseness, or allergies?

23. Anemia or blood transfusion?

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

25. 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?

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

24. Have you ever had an organ transplant or been an organ
donor?

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

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

11. History of aneurysm or blood clots?

29. Special education needs?

12. High blood pressure or high cholesterol ?
13. Esophagus, stomach, intestinal, rectal, liver,
gallbladder problems or hernia?

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

14. Have you had a colonoscopy or sigmoidoscopy?
Date (mm-dd-yyyy)

33. Have you ever been referred to or received mental health
treatment?

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

Primary Care PTSD Screen

16. Sexually-transmitted disease?

This questionnaire is intended to help you identify if you have the symptoms of
Post-Traumatic Stress Disorder (PTSD). Please answer the following four questions if
you have been assigned to a danger pay post in the last three years.

17. Serious infection?

In your life, have you ever had any experience that was so frightening, horrible, or
upsetting that, in the past month you:

34. Have had nightmares about it or thought about it when you
did not want to?
35. Tried hard not to think about it or went out of your way to
avoid situations that reminded you of it?
36. Were constantly on guard, watchful, or easily startled?

18. Cancer of any type?

37. Felt numb or detached from others, activities, or your
surroundings?
40. Have you ever had a mammogram?

Women Only
38. Do you have menstrual cycles?
Date of last menstrual period

41. Are you pregnant?

39. Have you had an abnormal PAP test in the last
5 years?

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

Date (mm-dd-yyyy) of last PAP test
Date (mm-dd-yyyy) of abnormal PAP
Result

Pregnant
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 1 to 42. 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

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VI. To Be Completed By The Examiner
1. Height

Name Of Examinee:

2. Weight

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

3. Pulse

in. or

lbs. or

cm.

kgs.

VII. Clinical Evaluation
Check each item as indicated. Check "NE" if not evaluated.

Normal Abnormal

NE

Notes
(Describe every abnormality in detail.
Include 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. Miscellaneous
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:
Examinee or sponsor must sign on page 2. Medical provider must sign on page 4.
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:
The preferred method to submit the DS-1843 is to scan and send by email to: [email protected].
If it is not possible to scan, then please fax the DS-1843 to Medical Records at Fax: 703-875-4850.
If you wish to confirm that your exam forms were received please email [email protected]

DS-1843

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X. All Tests Required Unless Otherwise Specified. Please attach all reports.

Name of Examinee:

1. Hematology

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

Hematocrit

Differential
%

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)

HIV I/II antibody
HepB surface antigen (if known
HBsAb pos. or has had
immunization, do not repeat)

Pos

Neg

b.

Pos

Neg

c.

Pos

Neg

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

If Not Done, Explain
Results:

HepC antibody

a.

WBC

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

RPR/VDRL

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

Specific
Gravity

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

a. Blood Type
mm of Induration

ABO

Previous Positive

Yes

No

(Rh) D

Previous Rx Complete

Yes

No

(weak) D

Yes

No

b. G6PD
Normal

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

u

Deficient

Treatment

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
Telephone Number

Address

Date (mm-dd-yyyy)

Fax Number
DS-1843

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