Ds-1843p Pre-employment Medical History And Examination For Forei

*OMB APPROVAL NO. 1405-0068
EXPIRATION DATE: 04-30-2012
ESTIMATED BURDEN: 1 HOUR

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

PRE-EMPLOYMENT MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE
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)

6. Place of Birth

7. Status

5. Sex
Male

State

City

Country

8. Name of your Health Insurance Plan

Applicant

Spouse

Son

Other

Female
Daughter

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

State

USAID

Foreign Agricultural
Service

Board of Broadcasting Governors

9. Purpose of Exam
Pre-Employment
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)

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)

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

To the Doctor: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title
II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this
law. To comply with this law we are asking that you NOT provide any genetic information when responding to this request for medical
information. 'Genetic information' as defined by GINA, includes an individual's family medical history, the results of an individual's or family
member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic
information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family
member receiving assistive reproductive services.
DS-1843P *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,
xx-2011
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
2. Dizzy spells, fainting, or seizures?

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

3. Neurological disorders?

20. Malaria or other tropical disease?

4. Chronic eye trouble, or vision problems?
Date of last eye exam (mm-dd-yyyy)

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

1. Frequent or severe headaches?

5. Tooth or gum problems?
6. Ear, nose, or throat problems, including
hearing difficulties, hoarseness, or allergies?

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

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?

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.
30.
31.
32.

12. High blood pressure or high cholesterol ?
13. Esophagus, stomach, intestinal, rectal, liver,
gallbladder problems or hernia?
14. Have you had a colonoscopy or sigmoidoscopy?
Date (mm-dd-yyyy)

Special education needs?
Have you ever used tobacco products?
Have you ever used alcohol?
Have you used marijuana, hallucinogenic drugs,
narcotics, or cocaine in the last 10 years?

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?

34. Do you practice safe sex?

16. Sexually-transmitted disease?

35. Are you at risk for AIDS?

17. Serious infection?

36. Do you exercise?

18. Cancer of any type?

37. Are you careful with your diet?
38. Do you have a living will?
39. Any other concerns you would like to address with the
clinician?

Women Only

42. Have you ever had a mammogram?

40. Do you have menstrual cycles?
Date of last menstrual period

43. Are you pregnant?
44. Are you nursing?

41. Have you had an abnormal PAP test in the last
5 years?
Date (mm-dd-yyyy) of last PAP test
Date (mm-dd-yyyy) of abnormal PAP

Pregnancy History: (number of times)
Pregnant
Premature births

Miscarriages
Abortions

III. Hospitalizations/Operations/Medical Evacuations (Include all medical and psychiatric illnesses.)
Date (mm-dd-yyyy)
Name of Hospital
Illness or Operation

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 44. 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-1843P

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VI. To Be Completed By The Examiner
1. Height
2. Weight

Name Of Examinee:
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.
The preferred method to submit the DS-1843P is to scan and send by email to: [email protected].
If it is not possible to scan, then please FAX the DS-1843P to Medical Records at Fax: 703-875-4850.

If you wish to confirm that your exam forms were received please email [email protected].

DS-1843P

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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)

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)

3. Serology (specify test and results) (12 years and over for
pre-employment and approx. every 5 years after)

Date (mm-dd-yyyy)

RPR/VDRL

10. Tuberculin Test (5TU PPD)
(recommended for all examinees including
those with previous BCG)

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

Pos

a.

Neg

b.

Pos

Neg

c.

Pos

Neg

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

Date (mm-dd-yyyy)
If Not Done, Explain
Results:

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

Results

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.

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

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
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-1843P

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