Form PC-1790S Report of Medical Examination

Guide to Completing the Report of Physical Examination
Getting it right the first time: Answers to commonly asked questions.

Page 4: Measurements and Other Findings
1) Hearing: Please ask the doctor to note either normal or abnormal after performing the following whisper test:
• The doctor stands at arms-length behind you.
• Cover your right ear.
• Ask doctor to whisper 2-3 numbers towards your left ear.
• Repeat what you heard the doctor say.
• Repeat test covering the left ear.
• Your hearing is normal if you respond correctly each time.

Page 4: Clinical Examination
1) Please document either normal or abnormal to all applicable questions. The only questions that may not be
applicable are the gender and age-specific questions, 12 and 15.

Page 4: Laboratory Evaluation
1) Tuberculin Test: If you choose to submit results from the PPD test, please submit them in mm of induration (in
number terms). Do not report “negative” as negative means different things to different doctors.
2) Lab Reports: Please ask the doctor for a copy of all lab results for the 8 lab tests listed under Other Required
Lab Tests.

Page 5: Immunizations Required for Medical Qualification
You must provide documentation that you have had all these immunizations in the noted timeframes (where
applicable) even if your doctor feels they are unnecessary.

Page 5: Immunization History
Please provide documentation for all immunizations in this section that you have previously had. Peace Corps
will provide all other immunizations needed once you become a Peace Corps Volunteer.

Page 6: Signature
This form must be signed or co-signed by an MD (Medical Doctor) or DO (Doctor of Osteopathy).

Peace Corps – Report of Medical Examination

Previous Editions are Obsolete

PC-OMS-1790S (Rev. 09/2009)

Page 1 of 6

PC-OMS-1790 S

Peace Corps Report of Physical Examination
Name (Last, First, Middle Initial)

/

Current Address Until

Telephone

No.

Sex

(

M ❐ F ❐

/

Social Security Number

Date of Birth (MO / DAY / YR)

/

/

Home/Permanent Address

)

Telephone

No.

(

)

Email

All sections must be completed

THIS SECTION TO BE COMPLETED BY APPLICANT

IV. Health History

A. Symptoms experienced within the past 12 months

Applicant: Answer each question by checking either Yes or No.
Physician: P
 lease review this list. If any are marked “yes,” please consider this a current problem requiring further comment
or work-up. Use space provided in Section X on page 6 (Summary and Comments) or additional pages if necessary,
identified with the applicant’s name and social security number.

Symptoms or problems
No

Frequent or severe headaches ❏
Fainting spells, blackouts or seizures ❏
Vision problems (e.g., eye injuries, disorders, inflammation)
❏
Hearing problems/loss ❏
Persistent cough ❏
Chest pain or chest pressure ❏
Shortness of breath or wheezing ❏
Repeated episodes of indigestion, heartburn, or stomach pain ❏
Frequent diarrhea or constipation
(such as colitis, irritable bowel syndrome) ❏
Frequent or bloody stools (such as Crohns disease)
❏
Frequent or painful urination ❏
Blood in urine
❏
Repeated episodes of back or neck pain
❏
Muscle, bone, or joint injuries ❏
Painful or swollen joints ❏
Breast lump or mass or nipple discharge
❏
Skin problems (e.g., eczema, dermatitis, psoriasis)
❏
Change in color or size of a mole or other growth
❏
A sore that does not heal ❏
Frequent sadness or feelings of depression
❏
Frequent or severe nervousness or anxiousness ❏
Frequent sleeplessness or insomnia ❏
Use of cigarettes or other tobacco products ❏
Chest palpitations
❏
Easy bleeding or bruising
❏
Swollen glands in neck

❏
Swelling in arms or legs ❏
(Females) Gynecologic symptoms or disorders ❏
(Males) Lumps in testicles ❏
(Males) Difficulty starting urine stream
or a decreased urine stream ❏
Other (please specify)
❏
Traumatic injuries (including accidents
motor vechicle, sports related, please specify)

❏
Hospitalizations (please specify)
❏
Surgeries (please specify) ❏
Name of surgery ___________________________________________________
Peace Corps – Report of Medical Examination

Yes
Yes
(Resolved) (Current) Physician comments

❏
❏
❏
❏
❏
❏
❏
❏

❏
❏
❏
❏
❏
❏
❏
❏

❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏

❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏

❏
❏

❏

❏
❏
❏

❏

❏
❏
❏
❏
❏
❏

❏

❏

❏

Date of surgery _____________________________
Previous Editions are Obsolete

PC-OMS-1790S (Rev. 09/2009)

Page 2 of 6

SSN

B. Family history

List family members (mother, father, siblings) who have had any of the following illnesses or problems:
❏ Alcoholism _______________
❏ Cardiovascular disease _______________
❏ Diabetes _______________

❏ Mental illness

_______________

❏ Cancer _______________

❏ Kidney Disease

_______________

❏ High blood pressure _______________

❏ Sudden death of a relative under age of 50

_______________

(Other than trauma)

❏ None

❏ Other (specify) _______________

C. List all current medications, including over-the-counter medications/supplements and herbals.

Please note, whenever possible, Peace Corps provides a generic equivalent and does not provide medications/supplements
considered not medically necessary.

Name

Start Date

Dose

Frequency

Condition Being Treated

_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________

❏ None

D. Allergies and hypersensitivities
List Allergies

Medications,
foods, and insect stings

Description
of Reaction

Treatment

Did treatment require
an ER visit?

Date of last reaction

❏ yes ❏ no
__________________________________________________________________________________________________________
❏ yes ❏ no
__________________________________________________________________________________________________________
❏ yes ❏ no
__________________________________________________________________________________________________________
❏ yes ❏ no
_______________________________________________________________________________________________________________
❏ yes ❏ no
_______________________________________________________________________________________________________________
❏ yes ❏ no
_______________________________________________________________________________________________________________
❏ None

*Important*

I certify that the above information is accurate and complete. I understand that the Peace Corps may verify the
information provided by me and my doctors. I understand that withholding or providing false or incomplete information will delay processing
my application and may result in disqualification from or termination of Peace Corps service.

HIPAA and Privacy Act Notice
This information is collected under the authority of the Peace Corps Act, 22 U.S.C. 2501 et seq., for the purposes of determining medical
and other eligibility for Peace Corps service. Disclosure of this information is voluntary, but without it the Peace Corps will be unable to
provide a medical clearance for service. This information may be used for the routine uses described in the Privacy Act, 5 USC 552a, and in
the Federal Register at 65 Fed. Reg. 53,722 (September 5, 2000) and 50 Fed. Reg. 1950, 1962 (January 14, 1985) regarding the Peace Corps
system of records PC-17 (Volunteer Records). It may also be used in compliance with the Health Insurance Portability and Accountability Act
(HIPAA) and any currently effective authorizations.
_________________________________________________
Signature

_________________________________________________
Date

Peace Corps – Report of Medical Examination

Previous Editions are Obsolete

PC-OMS-1790S (Rev. 09/2009)

Page 3 of 6

SSN

V. Measurements and Other Findings
Height

Weight

Blood Pressure

Pulse

Gross Vision

Hearing

Uncorrected
Corrected
Right 20/_____ Right 20/_____
Left
feet/inches

lbs.

(resting)

VI. Clinical Examination

All Sections MUST be completed by examining physician
Check each item in appropriate column.
All systems must be examined.

❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏

whisper test or
other gross test

Left

20/_____

complete prescription for eyeglass
form if uncorrected vision of 20/40
or greater

Prior to this visit have you provided medical care to this applicant?

❏ yes ❏ no
If yes, how many times in the past 12 months have you seen this applicant?
Notes: D
 escribe each abnormality in detail. Enter item number before
each comment. Use additional sheets if necessary.

Normal Abnormal

❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏

bpm (resting)

20/_____

1. Head and neck
2. Nose, sinuses
3. Mouth and throat
4. Thyroid
5. Ears
6. Eyes (include fundoscopic exam)
7. Lungs and chest
8. Breasts
9. Cardiac (rate, rhythm, heart sounds)
10. Peripheral pulses
11. Abdomen
12. Prostate exam (men over 50 only)
13. Anus and rectum
14. Genitalia (include hernia)
15. Pelvic exam (females only)
16. Spine
17. Musculoskeletal
18. Neurologic
19. Skin, lymphatics
20. Identifying marks, scars, tattoos
21. Psychiatric (specify any significant cognitive
or behavioral observations)

VII. Laboratory Evaluation

Abnormal lab results require an explanation, a treatment plan or, if chronic abnormality, historical results with a plan for follow up.

PAP Smear cytology results
Date _______________________________
Lab report peformed no more than 1
year prior to the physical exam MUST
be attached

Tuberculin Test
TB test performed no more than 6 months prior to physical exam

❏ PPD
Date read _______________________________

Lab report peformed no more than
6 months prior to the physical exam
MUST be attached

❏ HIV (bloodwork or rapid oral test)

Size of induration must be recorded in box below.

❏ CBC

Do not report “Negative”

❏ Hepatitis B surface Antibody

mm of induration

OR

❏ QuantiFERON® - TB gold (lab report must be attached)
❏ negative
❏ positive
Peace Corps – Report of Medical Examination

Other Required Lab Tests

Previous Editions are Obsolete

❏ Hepatitis B surface Antigen
❏ Hepatitis B core Antibody
❏ Hepatitis C Antibody
❏ G6PD titer
❏ Urinalysis
PC-OMS-1790S (Rev. 09/2009)

Page 4 of 6

SSN

VIII. Immunizations Required for Medical Qualification:
Physician - Initial & Date Administration
Type of Immunization

Date of Immunization

Physician Initials

1. Td or Tdap Booster

(within 5 years of the Report of

Medical Examination)
_____________________________________________________________________________________________________________________________________________________________________________________________________

2. Polio Booster

(after age 18 or documentation by
physician of having had the disease)

____________________________________________________________________________________________________________________________________________
3. MMR#1

____________________________________________________________________________________________________________________________________________

4. MMR#2
Booster
_____________________________________________________________________________________________________________________________________________________________________________________________________

If born before 1957, may instead provide documentation of one measles-containing vaccine, documentation of physiciandiagnosed measles, or documentation of titers demonstrating immunity to all 3 diseases.
If born 1957 or after, may instead provide documentation of titers demonstrating immunity to all 3 diseases.
5. Varicella #1

_____________________________________________________________________________________________________________________________________________________________________________________________________

6. Varicella #2

_____________________________________________________________________________________________________________________________________________________________________________________________________
If born before 1980, may instead provide documentation of physican-diagnosed chicken-pox or herpes zoster.
If born 1980 or after, may instead provide titers demonstrating immunity to varicella.

Immunization History:

Do NOT Give These Immunizations.
Has the applicant received the following immunizations?
If yes to any of the following, please attach copy of the immunization records.
Yes

❏
1. Yellow Fever
2. Hep B Series

❏
3. Hep A Series
❏
4. Typhoid
❏
5. Rabies Pre-Exposure
❏
6. Meningococcal
❏
7. Japanese Encephalitis
❏
8. Tick-borne Encephalitis
❏
9. Influenza
❏
10. Pneumococcal
❏
11. Other (please specify)
❏

No

❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏

IX. Required Tests for Female Applicants 40 Years and Older.
Mammogram (females only)
(Attach radiology report performed no more than 1 year prior to physical exam)

Tests for Applicants 50 Years and Older.
Colorectal Screening (any ONE test) (Results must be attached)

❏ Colonoscopy (within 10 years)

❏ ECG Interpretation
(ECG tracing performed no more than 1
year prior to the physical exam MUST be
faxed to Peace Corps at 202.692.1561)

❏ Flexible Sigmoidoscopy (within 5 years)
❏ Double Contrast Barium Enema (within 5 years)
❏ CT Colonography "Virtual Colonoscopy" (within 5 years)
❏ Stool DNA Testing (within 1 year)
❏ Fecal Immunochemical Test (FIT) (within 1 year)
❏ Fecal Occult Blood Test (FOBT)x3 - Stool for occult blood (within 1 year)

Peace Corps – Report of Medical Examination

Previous Editions are Obsolete

PC-OMS-1790S (Rev. 09/2009)

Page 5 of 6

SSN

X. Summary of the Medical Examination and Additional Comments
Provide your summary and assessment of the medical examination. Comment on all abnormal findings including recommendations
for evaluation and/or treatment required for the next three years of service in a developing country. If additional pages are required,
include applicant’s name and social security number on each page.
List all Active and Chronic Conditions

Recommendations & Comments

1 ___________________________________________________________________________________________________________
2 ___________________________________________________________________________________________________________
3 ___________________________________________________________________________________________________________
4 ___________________________________________________________________________________________________________
5 ___________________________________________________________________________________________________________
6 ___________________________________________________________________________________________________________

1. Do you have any medical concerns about the applicant that might limit his/her assignment to a specific geographic area
(e.g. mountainous terrain, high altitude, sun exposure, harsh environmental or climatic conditions, etc?) YES ❏ NO ❏ If yes, specify
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

(must be signed or co-signed by a licensed M.D. or D.O. if exam performed by other than M.D. or D.O.)

*Important*

Medical examination is complete only when:

• Applicant has signed and dated statement on page 3.
• Physician has signed and dated page 6.
• Physician has initialed all documented immunizations on page 5.
• Required lab reports are attached.
• PAP, ECG tracing and mammography report are attached (when indicated).

_________________________________________________
Physician Signature/Title

_________________________________________________
Physician Name (Print)

_________________________________________________
Date

Physician License Number/State

________________________________________________
________________________________________________
_________________________________________________
_________________________________________________
Physician Address and Phone Number

INCOMPLETE FORMS WILL BE RETURNED TO THE APPLICANT AND WILL DELAY PROCESSING!
Peace Corps – Report of Medical Examination

Previous Editions are Obsolete

PC-OMS-1790S (Rev 0.9/2009)

Page 6 of 6