Form PC-1789 Health Status Review

Authorization for Peace Corps Use of Medical Information
This authorization permits the Peace Corps to use my protected health information to determine my eligibility for the Peace Corps and as necessary for administration of the Peace Corps program. This document must
be signed, dated, and returned with your medical information. We will be unable to review your
information without this signed document!
I, ______________________________________, hereby authorize that:

A . All health information I provide to the Peace Corps or that is provided by anyone who has provided health
care services or treatment to me, consulted on such services, or otherwise has health care information
responsive to the information requests of the Peace Corps, including my response to the Health Status Review,
and any follow-up health information requested by and provided to the Peace Corps Office of Medical Services
relating to me prior to my being sworn in as a Peace Corps Volunteer (including but not limited to information
about my prior physical and mental health history, my current health status, and possible future care and
treatment), may be disclosed to the following people:
Peace Corps staff, including in the Office of Medical Services, Office of Special Services, Office of Volunteer
Recruitment Selection, Office of Safety and Security, Office of General Counsel, appropriate Regional Operations
offices, Peace Corps Medical Officers, Country Directors at overseas posts, and any other Peace Corps staff or
contractors who have a need to know the information to perform their duties, for the purposes of making a
determination of my medical or other eligibility for Peace Corps service and of placement/assignment.
B. If I am accepted for Peace Corps service, the information listed above will become part of my Peace Corps
health record. All information in my Peace Corps health record, and any other personal health information
relevant to me that is provided to the Peace Corps by me or any health care provider or other person, may be
disclosed to Peace Corps staff or contractors, as described in paragraph A above, who have a specific need to
know the information for the purposes of performing their duties in connection with administration of the
Peace Corps program only. This may include (but is not limited to) information relevant to my continued
service as a Peace Corps trainee or Peace Corps Volunteer.
This authorization is effective until five years following either my close of Peace Corps service or final
determination by the Peace Corps that I am not eligible for Peace Corps service. I understand that I may revoke
this authorization at any time by sending a written revocation to the Office of Medical Services, Peace Corps,
1111 20th Street, NW, Washington DC, 20526, but that my revocation before acceptance will stop consideration
of my application, and that my service as a Volunteer is conditioned on the existence of this authorization,
which is necessary to administer the Peace Corps program.
I also understand, however, that during the entire period of my authorization to use my health care
information, Peace Corps will protect the confidentiality of my health care information, consistent with the
Privacy Act, the Health Insurance Portability and Accountability Act (as applicable), and Peace Corps policies
on confidentiality of medical information, as described in the Peace Corps Notice of Privacy Practices.
I have read and understand this authorization.

Signature Date DOB

Peace Corps – Health Status Review

PC-1789

3/2010

HIPAA FOR APPLICANTS- FAQs
(please keep this for your records)
What is HIPAA?

So, what does this mean for me as an applicant?

HIPAA – the Health Insurance Portability and
Accountability Act – is a set of federal laws and
regulations designed in part to protect information
about your health care from unreasonable disclosure.
It limits the extent to which your “protected health
information” -- individually identifiable information
about your health condition or treatment -- can be used
for purposes other than treatment and payment, and
the business operations to support them. HIPAA also
requires individuals to be given a notice describing how
medical professionals and health plans use their medical
information; most of you have probably received these
kinds of notices from your doctors over the last year or
so. Peace Corps’ notice is available on its website. www.
peacecorps.gov/policies/pdf/hipaa.pdf

Since Peace Corps Volunteers (PCVs) spend their time in
places with relatively less sophisticated sanitation and
health care networks, and in countries with higher level
of endemic illness, all applicants must get a medical
clearance before they are invited to join the Peace Corps.
Your medical status is a key factor in your eligibility to
be a Volunteer. To do this medical screening, the Peace
Corps needs access to information about your medical
status. Under the formalities of HIPAA , we are required
to ask you to authorize us to receive such information
and to use it for screening and for placement purposes;
without that authorization, we will not be able to provide
the necessary medical clearance for you to be a Volunteer.

What impact does HIPAA have on the Peace Corps?
As you probably know, the Peace Corps provides medical
care to its Volunteers while they are overseas. It also pays
for certain tests and exams before, during, and after
Peace Corps service.
Even without HIPAA , the Peace Corps takes its
responsibilities to protect the confidentiality of your
medical information very seriously. Peace Corps policy
strictly limits disclosure of such information only to
those who have a need to know it to do their jobs; and
they all are required to protect its confidentiality. This
policy, which applies to Peace Corps wherever Peace
Corps operates, is consistent with our obligations under
the Privacy Act, a federal law applying to all federal
agencies. The Privacy Act permits only those agency staff
with the need to use the information to do their jobs to
use personal information in agency files, such as medical
records.
The Peace Corps does much more than provide medical
services. It provides diverse support to more than 7500
Volunteers in more than 70 countries. This includes
recruiting, giving medical clearance, placing thousands
of Volunteers each year, training them, protecting
their safety and security, providing program support
to them overseas, and ensuring that the whole Peace
Corps system operates as effectively and efficiently as
possible. Administration of the program does sometimes
(although relatively rarely) require the use of health
information about an applicant or Volunteer for reasons
other than for medical care; e.g., in ensuring the safety
and security of Volunteers.
Because HIPAA puts strict limits on the use of personal
health information in the U.S., the Peace Corps is
required to observe the formality of getting a signed
authorization from you to use your medical information
for most purposes other than for treatment. The Peace
Corps is not changing the confidential way it uses
medical information. What has changed is the law about
the permissible routine use of such information.
Peace Corps – Health Status Review

So, one piece of the application kit is an “Authorization
For Peace Corps Use of Medical Information.” This
document must be signed and returned to the Peace
Corps as part of the application. Without it, we cannot
consider your application.
This authorization also will permit us to use medical
information as described below if and when you become
a Volunteer.
What will this mean for me as a Volunteer?
If you are accepted for Peace Corps service, the medical
information that was part of your application and
the medical screening is put into your health record,
which goes with you overseas. The Peace Corps Medical
Officer(s) in your country will use and add to the
information as they care for you.
For the most part, your medical information is used for
treatment and payment purposes only. This information
may be disclosed to Peace Corps staff in-country and
in the U.S. on a need-to-know basis. But, there are
occasional situations where Peace Corps staff in the U.S.
need access to information about your medical situation
for non-treatment purposes in order to provide support
to and manage the Peace Corps Volunteer program itself.
For example, there may be times when it is relevant to
protecting your safety and security, and that of your
fellow Volunteers. It may be relevant to whether it is
appropriate for you to continue to serve as a Volunteer.
The authorization HIPAA requires us to get from you
permitting us to use medical information for program
administration purposes included in the “Authorization
For Peace Corps Use of Medical Information.” The
protections of the Privacy Act apply, and the information
will be used only by those Peace Corps staff who have
a specific need to know the information to do their job,
and only for those limited purposes. We appreciate your
cooperation.

PC-1789

3/2010

OMB # 0420-0510
Expiration Date: 07/31/2011

Peace Corps Volunteer Medical Application
HEALTH STATUS REVIEW
1. Name___________________________________________________________________________________________________
First

Middle (not initial)

3. Gender

2. Social Security Number _____–_____–______
The Peace Corps asks for your Social Security number, or SSN, because the
Peace Corps Act (22 U.S.C. 2519) requires a background check on all Volunteers.
Your SSN is needed for this background check, so providing it is mandatory.
The Peace Corps will also use it to ensure that our records are accurate, and
for tax and other financial accounting purposes.

Day

Female

❑ Male

6. Date of Birth: _______/_______/_________

Year

Month

Day

Year

8. Weight: _____________

7. Height: ______/_______
Feet

❑

4. Are you a returned Peace Corps Volunteer?
❑ Yes ❑ No

5. Today’s Date: _______/_______/_________
Month

Last

Lbs

Inches

9. Are you applying with your spouse?

❑ Yes

❑ No

10. Have you ever smoked cigarettes or used tobacco products? ❑ Yes
A. If yes, do you currently smoke or use tobacco? ❑ Yes

❑ Never

❑ No

B. If you are a former smoker, have you smoked or used tobacco products in the last 5 years? ❑ Yes
11. Do you currently wear dental braces? ❑ Yes

❑ No

❑ No

(This does NOT include removable orthodontic retainers, dentures, partial plates, or bridges)

14. Other than tonsillectomy, childhood tonsillitis
or wisdom teeth extraction, have you had any
condition or have you had any surgery on your
ears, nose, face, sinuses, jaw or throat not listed
in 11-12? ❑ Yes ❑ No

12. Do you have or have you ever had?
A. Meniere’s Disease? ❑ Yes

❑ Never

B. Multiple inner ear infections after age 15?
❑ Yes ❑ Never
C. Tinnitus? (Ringing in the ear) ❑ Yes

❑ Never

D. Vertigo? (Dizziness due to an inner ear problem)
❑ Yes ❑ Never

If yes, please specify:
______________________________________________
______________________________________________

13. Do you currently require the use of one hearing
aid? ❑ Yes
❑ No

OPHTHALMOLOGY
15. Do you have or have you ever had?
A. Glaucoma? (Mark resolved if you no longer see a physician
regarding this condition and/or no longer have symptoms)

❑ Yes

❑ Resolved

❑ Never

B. Herpes infection of the cornea? (herpes keratitis)
❑ Yes ❑ Never
C. Optic neuritis? ❑ Yes

❑ Never

D. Chronic uveitis or iritis? ❑ Yes

16. Other than astigmatism or use of corrective
lenses, have you had any other condition or
surgery of the eye not listed in item 15?
❑ Yes ❑ No
If yes, please specify:
______________________________________________
______________________________________________

❑ Never

E. Cataracts/Cataract surgery? ❑ Yes

❑ Never

F. Other vision correcting surgery, such as RK, PRK,
LASIK?❑ Yes ❑ Never
G. Macular or lattice degeneration (degeneration of
the retina)? ❑ Yes ❑ Never
H. Retinal detachment?❑ Yes
I. Eye Trauma? ❑ Yes
Peace Corps – Health Status Review

❑ Never

❑ Never
PC-1789

3/2010

ALLERGIES/SENSITIVITIES
19. During an allergic reaction, have you ever had:

17. Are you allergic to:
A. Penicillin? ❑ Yes

A. Difficulty breathing? ❑ Yes

❑ No

❑ Never

B. Sulfa drugs? (such as Bactrim, Septra)
❑ Yes ❑ No

B. Loss of consciousness?
❑ Yes ❑ Never

C. Other medication(s)? ❑ Yes

C. Severe swelling of your nose, lips, tongue or
throat? ❑ Yes ❑ Never

D. Eggs?

❑ Yes

❑ No

E. Peanuts? ❑ Yes

❑ No

F. Shellfish? ❑ Yes

❑ No

G. Other food(s)? ❑ Yes

❑ No

D. Emergency treatment in a medical facility for an
allergic reaction?
❑ Yes ❑ Never
20. Are you sensitive to:

❑ No

H. Bee, wasp or other insect stings?❑ Yes

❑ No

I. Environmental allergies (such as grass, pollen, dust
animal hair, etc)? ❑ Yes ❑ No
J. Sun Screen? ❑ Yes

❑ No

A. Gluten? ❑ Yes

❑ No

B Lactose? (milk or dairy intolerance)
❑ Yes ❑ No
C. Sunlight? ❑ Yes

❑ No

D. Sun Screen?❑ Yes

18. Do you require allergy shots? ❑ Yes

❑ No

❑ No

PULMONARY/RESPIRATORY
22. Since age 15, have you ever:

21. Do you have or have you ever had:
A. Chronic bronchitis? ❑ Yes

A. Experienced wheezing? ❑ Yes

❑ Never

B. Used an inhaler to prevent breathing problems or
to help you breathe?
❑ Yes ❑ Never

B. Emphysema or COPD?
❑ Yes ❑ Never
C. Pulmonary Disease? ❑ Yes

❑ Never

C. Been told you have asthma, bronchospasm or
reactive (restrictive) airway disease?
❑ Yes ❑ Never

D. Removal of a lung or a lobe of the lung?
❑ Yes ❑ Never
E. Pneumonia more than once during the last 5
years? ❑ Yes ❑ Never
F. Collapsed lung (Pneumothorax)?
❑ Yes ❑ Never
G. Cystic Fibrosis? ❑ Yes

❑ Never

23. Within the last 5 years, have you had any
respiratory condition, lung condition or surgery
not listed in items 21-22? ❑ Yes ❑ Never
If yes, please specify:

❑ Never

____________________________________________
____________________________________________

CARDIOVASCULAR
24. Do you take prescription medication to control
❑ No
your blood pressure? ❑ Yes

27. Do you have or have you ever had:
A. Pacemaker? ❑ Yes

❑ Never

25. Do you take prescription medication for high
❑ No
cholesterol or high triglycerides? ❑ Yes

B. Coronary artery disease?
❑ Yes ❑ Never

26. Do you have or have you ever had:

C. Congestive heart failure?
❑ Yes ❑ Never

A. Angina? ❑ Yes

❑ Never

B. A heart attack?
❑ Yes ❑ Never

D. A disturbance of heart rhythm (arrhythmia)?
❑ Yes ❑ Never

C. Coronary artery or heart by-pass surgery?
❑ Yes ❑ Never

E. An aneurysm? ❑ Yes

D. Coronary angioplasty (“balloon angioplasty”) or
insertion of stent(s)?
❑ Yes ❑ Never
E. Other heart surgery? ❑ Yes
F. Carotid artery surgery?❑ Yes

F. An implantable defibrillator?❑ Yes

❑ Never

❑ Never
❑ Never

G. Other surgery of the arteries? ❑ Yes
Peace Corps – Health Status Review

❑ Never

❑ Never
PC-1789

3/2010

CARDIOVASCULAR CONTINUED
28. Continued:

28. Do you have or have you ever had:
A. A heart murmur present after age 15?
❑ Yes ❑ Never

H. Varicose veins? (Mark resolved if you no longer see a
physician regarding this condition and/or no longer have
symptoms)

B. Heart valve disease?
❑ Yes ❑ Never

❑ Yes

❑ Resolved

❑ Never

I. Chronic leg or ankle swelling? (Mark resolved if you no

C. Mitral valve prolapse?
❑ Yes ❑ Never
D. Raynaud’s disease (Vasospasm in parts of the
hands)?
❑ Yes ❑ Never
E. A blood clot in the lung (Pulmonary embolism)?
❑ Yes ❑ Never
F. A blood clot in the legs (Thrombophlebitis)?​
❑ Yes ❑ Never
G. Problems caused by poor circulation?
❑ Yes ❑ Never

longer see a physician regarding this condition and/or no longer
have symptoms)

❑ Yes

❑ Resolved

❑ Never

29. Other than aspirin, do you currently or have you
ever taken any blood-thinning (anti-coagulant)
medication such as Warfarin or Coumadin?
(Mark resolved if you no longer see a physician regarding this
condition and/or no longer have symptoms)

❑ Yes

❑ Resolved

❑ Never

30. Do you have or have you ever had any other heart
or circulatory condition or surgery not listed in
items 24-29? ❑ Yes ❑ Never
If yes, please specify:
_______________________________________________
_______________________________________________

GASTROINTESTINAL
31. Do you have or have you ever had:
A. An esophageal stricture?
❑ Yes ❑ Never

J. Diverticulosis/diverticulitis? (Mark resolved if you no

B. Heartburn requiring daily medication? (Mark resolved
if you no longer take heartburn medication and no longer have
symptoms)

❑ Yes

❑ Resolved

❑ Never

C. Esophageal varices?
❑ Yes ❑ Never
(Mark resolved if you no longer see a physician regarding this
condition and/or no longer have symptoms)

❑ Resolved

❑ Never

E. Gall Bladder disease? (Mark resolved if you no longer
see a physician regarding this condition and/or no longer have
symptoms)

❑ Yes

❑ Resolved

❑ Never

F. Cirrhosis of the liver?​ ❑ Yes

❑ Never

G. Pancreatic disease? ❑ Yes

❑ Never

H. Irritable Bowel Syndrome?
❑ Yes
❑ Resolved ❑ Never
I. Inflammatory Bowel Disease/Crohn’s/Ulcerative
Colitis? (Mark resolved if you no longer see a physician
regarding this condition and/or no longer have symptoms)

❑ Yes

❑ Resolved

longer see a physician regarding this condition and/or no
longer have symptoms)

❑ Yes

❑ Resolved

❑ Never

K. Gastric Bypass Surgery (Bariatric Surgery) or other
weight loss surgery?
❑ Yes ❑ Never
32. Do you have or have you ever had:

D. Stomach or duodenal ulcers/Peptic ulcer disease?
❑ Yes

31. Continued:

❑ Never

A. A hernia of the groin (inguinal) or abdomen?
(Mark resolved if you no longer see a physician regarding this
condition and/or no longer have symptoms)

❑ Yes

❑ Resolved

❑ Never

B. A colostomy or an ileostomy? ❑ Yes

❑ Never

33. Do you have or have you ever had:
A. A cyst near the rectum (pilonidal cyst)?​
❑ Yes ❑ Never
B. Internal hemorrhoids?
❑ Yes ❑ Never
34. Do you have or have you ever had any other
conditions or surgery of the esophagus,
stomach, liver, gall bladder, pancreas or
intestinal tract not listed in items 31-33?
❑ Yes ❑ Never
If yes, please specify:
_____________________________________________
_____________________________________________

Peace Corps – Health Status Review

PC-1789

3/2010

GENDER
35. Have you undergone sexual reassignment to change your gender?
B. If yes, were you born male or female?

❑ Male

❑ Yes

❑ No

❑ Female

Male Gender-Specific/Genitourinary (Males Only)
36. Do you have or have you ever had:
A. Difficulty starting or stopping your urine stream?
❑ Yes ❑ Never

37. Do you have or have you ever had any other
genital condition or surgery not listed in item 36?
❑ Yes ❑ Never
If yes, please specify:
_______________________________________________
_______________________________________________

B. An enlarged prostate?
❑ Yes ❑ Never
C. Prostate Cancer?
❑ Yes ❑ Never
D. Pain or swelling in your testicles?
❑ Yes ❑ Never
E. Hydrocele, spermatocele or varicocele?
❑ Yes ❑ Never
F. Testicular Cancer?​
❑ Yes ❑ Never
G. Erectile Dysfunction requiring medication?
❑ Yes ❑ Never

Female Gender-Specific/Gynecology (Females Only)
40. Continued:

38. Are you currently using:
A. Birth control pills?
❑ Yes ❑ No

D. Polycystic Ovarian Syndrome?
❑ Yes
❑ No

B. Birth control implants (Norplant®)?
❑ Yes ❑ No

E. Ovarian Cysts? (Mark resolved if you no longer see a

C. Birth control injections (such as Depo-Provera)?
❑ Yes ❑ No
D. An Intrauterine device (IUD)?
❑ Yes ❑ No
E. Intra-vaginal contraception such as NuvaRing®?
❑ Yes ❑ Never
39. Have you ever had:

B. If yes, have you ever had an abnormal Pap smear?
❑ Yes ❑ Never
40. Do you have or have you ever had:
A. Pelvic Inflammatory disease (PID) or tubal
infections? (Mark resolved if you no longer see a physician
regarding this condition and/or no longer have symptoms)

❑ Resolved

❑ Never​

B. Uterine fibroids? (Mark resolved if you no longer see a
physician regarding this condition and/or no longer have
symptoms)

❑ Yes

❑ Resolved

❑ Yes

❑ Resolved

❑ Never

41. Do you currently have:
A. Menstrual cycles?
❑ Yes
❑ No
B. Irregular menstrual cycles (NOT monthly)?
❑ Yes
❑ No
C. Bleeding or spotting between menstrual cycles?
❑ Yes
❑ No

A. A pap smear?​
❑ Yes ❑ Never

❑ Yes

physician regarding this condition and/or no longer have
symptoms)

42. Are you:
A. Post-menopausal NOT due to removal of uterus
(hysterectomy)?
❑ Yes
❑ No
B. Post-menopausal with any vaginal bleeding or
spotting?
❑ Yes
❑ No
C. Receiving hormone replacement therapy (HRT)?
❑ Yes
❑ No
43. Have you had your uterus removed
(hysterectomy)? ❑ Yes
❑ No

❑ Never

C. Endometriosis? (Mark resolved if you no longer see a
physician regarding this condition and/or no longer have
symptoms)

❑ Yes

❑ Resolved

Peace Corps – Health Status Review

❑ Never

PC-1789

3/2010

Female Gender-Specific/Gynecology Continued (Females Only)
46. Within the last five years, have you had any other
gynecological conditions or surgery not listed in
items 38-45? ❑ Yes ❑ Never

44. Do you have or have you ever had:
A. A breast cyst or lump?
❑ Yes ❑ Never
B. Fibrocystic breast changes?
❑ Yes ❑ Never

If yes, please specify:
______________________________________________
______________________________________________

C. Breast implants?
❑ Yes ❑ Never
D. Breast cancer?
❑ Yes ❑ Never
45. Within the last six months, have you had a
colposcopy procedure due to an abnormal PAP?
❑ Yes ❑ No

NEPHROLOGY
47. Have you had four or more bladder infections
❑ No
(cystitis) in the past year? ❑ Yes
48. Have you had two or more kidney infections
(pyelonephritis) in the past two years?
❑ Yes
❑ No
49. Have you ever had kidney stones? ❑ Yes

50. Do you have or have you ever had any urinary,
bladder, or kidney condition or surgery not listed
in items 47-49? ❑ Yes ❑ Never
If yes, please specify:
______________________________________________
______________________________________________

❑ No

DERMATOLOGY
51. Do you have or have you ever had:

52. Within the last five years, have you had any other
skin condition not listed in item 51 for which you
are taking prescription medication or receiving
medical treatment? ❑ Yes ❑ No

A. Eczema?
❑ Yes ❑ Never
B. Psoriasis?
❑ Yes ❑ Never
C. Basal cell tumor(s) of the skin?
(Mark resolved if you no longer see a physician regarding this
condition and/or no longer have symptoms)

❑ Yes

❑ Resolved

If yes, please specify:
______________________________________________
______________________________________________

❑ Never

D. A Cancerous mole or other skin cancer (not basal
cell)? ❑ Yes ❑ Never
E. Acne currently requiring prescription medications?
❑ Yes ❑ Never

ORTHOPEDIC
53. Have you ever had an accident or event resulting
in a head or traumatic injury? ❑ Yes
❑ No
54. Within the last five years, have you ever broken
any of the following bones?
A. Back (spine) or neck?
❑ Yes ❑ No
B. Hip?
❑ Yes

❑ No

C. Skull?
❑ Yes

❑ No

D. Pelvis?
❑ Yes ❑ No

55. Do you have or have you ever been medically
treated or had surgery:
A. Chronic or recurrent neck or back pain (excluding
arthritis)?
❑ Yes ❑ Never
B. Pinched Nerves?
(Mark resolved if you no longer see a physician regarding this
condition and/or no longer have symptoms)

❑ Yes

❑ Resolved

❑ Never

C. A Disc problem? ❑ Yes

❑ Never

D. Scoliosis or kyphosis?
(Mark resolved if you no longer see a physician regarding this
condition and/or no longer have symptoms)

❑ Yes

❑ Resolved

❑ Never

E. Osteoporosis or Osteopenia? ❑ Yes
Peace Corps – Health Status Review

❑ Never

PC-1789

3/2010

ORTHOPEDIC CONTINUED
56. Other than for arthritis or bursitis, have you been
medically or surgically treated for:
A. Chronic shoulder pain, dislocation or rotator cuff
injury?
❑ Yes ❑ Never
B. Chronic hip pain?

❑ Yes

❑ Never

C. Chronic ankle pain (excluding uncomplicated ankle
strains or sprains)?
❑ Yes ❑ Never
D. Chronic knee pain?

❑ Yes

❑ Never

57. Have you ever had
A. Shoulder arthroscopy, ligament repair,
reconstruction or replacement?
❑ Yes ❑ Never
B. Hip reconstruction or replacement?

❑ Yes

❑ Never

C. Knee arthroscopy, ligament repair, reconstruction
or replacement? ❑ Yes ❑ Never
D. Orthopedic hardware (pins, plates, rods, screws,
etc)?
❑ Yes ❑ Never
58. Do you have arthritis or bursitis that requires the
use of prescription medication?
❑ Yes

59. Do you have or have you ever had:
A. Repetitive motion injury/syndrome?
❑ Yes
❑ Never
B. Carpal tunnel syndrome? ❑ Yes

❑ Never

60. Do you have or have you ever had:
A. Painful bunions?
❑ Yes
❑ Never
B. Foot pain?

❑ Yes

❑ Never

C. Fascitis?

❑ Yes

❑ Never

D. The need to use orthotics as treatment for a foot
or other condition? ❑ Yes ❑ Never
61. Within the last five years, have you had or been
treated for any acute or chronic joint, muscle or
bone condition or surgery not listed in items 5360? ❑ Yes ❑ Never
If yes, please specify:
______________________________________________
______________________________________________

❑ Never

RHEUMATOLOGY
62. Continued

62. Do you have or have you ever had:
A. Fibromyalgia?

❑ Yes

❑ Never

B. Ankylosing spondylitis? ❑ Yes

❑ Never

C. Rheumatoid arthritis?

❑ Never

❑ Yes

E. Reactive arthritis (Reiter’s Syndrome)?
❑ Yes ❑ Never
F. Systemic Lupus Erythematosis (SLE)?
❑ Yes ❑ Never

D. Juvenile rheumatoid arthritis?
❑ Yes ❑ Never

G. Connective Tissue disorder? ❑ Yes

❑ Never

H. Myasthenia Gravis (Variable neuro-muscular
weakness)? ❑ Yes ❑ Never

HEMATOLOGY
63. Do you have or have you ever had:
A. Iron deficiency anemia? ❑ Yes

❑ Never

B. Anemia due to folate or B-12 deficiency/Pernicious
anemia? ❑ Yes ❑ Never
C. A low platelet count (thrombocytopenia)?
❑ Yes ❑ Never
D. A missing or diseased spleen?
❑ Yes ❑ Never

64. Do you have or have you had any other blood,
immune system, connective tissue or collagen
condition not listed in items 62-63?
❑ Yes ❑ Never
If yes, please specify:
______________________________________________
______________________________________________

E Hemochromatosis?
❑ Yes ❑ Never
F. Sickle cell disease?
❑ Yes ❑ Never
G. Thalessemia?
❑ Yes ❑ Never
H. A clotting disorder?
❑ Yes ❑ Never
I. Polycythemia vera?
❑ Yes ❑ Never
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ENDOCRINOLOGY
65. Do you have diabetes? ❑ Yes

❑ No

67. Continued:

A. If yes, do you use oral medication?
❑ Yes ❑ No

D. An underactive thyroid (Hypothyroidism)?
❑ Yes ❑ Never

B. Insulin injections? ❑ Yes

❑ No

C. An insulin pump? ❑ Yes

❑ No

E. Other thyroid disease?
❑ Yes ❑ Never

66. Do you have or have you ever been treated for
gout? ❑ Yes ❑ Never
67. Do you have or have you ever had:
A. A thyroid goiter?(Mark resolved if you no longer see a
❑ Resolved

❑ Never

B. A thyroid nodule? (Mark resolved if you no longer see
a physician regarding this condition and/or no longer have
symptoms)

❑ Yes

❑ Resolved

69. Do you have Addison’s Disease (Underactive
adrenal gland)? ❑ Yes ❑ Never
70. Do you have or have you ever had any condition
of the endocrine system not listed in items 6569? ❑ Yes ❑ Never

physician regarding this condition and/or no longer have
symptoms)

❑ Yes

68. Do you have or have you ever had a disease of
the pituitary gland? ❑ Yes ❑ Never

❑ Never

If yes, please specify:
______________________________________________
______________________________________________

C. An overactive thyroid (Hyperthyroidism)?
❑ Yes ❑ Never

INFECTIOUS DISEASE
71. Did you have a blood transfusion before July
1992? ❑ Yes ❑ No

73. Do you have or have you ever had:
A. Chronic fatigue syndrome? ❑ Yes ❑ Never

72. Do you have or have you ever had (this does NOT refer
to immunizations):

A. Hepatitis A virus? (Mark resolved if you no longer see
a physician regarding this condition and/or no longer have
symptoms)

❑ Yes

❑ Resolved

❑ Never

B. Hepatitis B virus? ❑ Yes

❑ Never

C. Hepatitis C virus? ❑ Yes

❑ Never

D. HIV/AIDS? ❑ Yes

B. A positive skin test for tuberculosis?
❑ Yes ❑ Never
C. Tuberculosis disease of the lungs or other organ?
❑ Yes ❑ Never
D. Lyme Disease? ❑ Yes

❑ Never

74. Other than a cold or the flu, do you currently
have any other infectious or parasitic condition
not listed in items 72-73? ❑ Yes ❑ Never

❑ Never

If yes, please specify:
______________________________________________
______________________________________________

NEUROLOGY
75. Do you have severe or migraine headaches that
require prescription medication? ❑ Yes ❑ Never
76. Have you ever had any seizures or convulsions?
❑ Yes ❑ Never
If yes, were they prior to the age of five and
associated with a high fever? ❑ Yes ❑ Never
77. Have you ever had a stroke or stroke-like
symptoms (TIA, Mini-stroke)? ❑ Yes ❑ Never
78. Do you have:

Peace Corps – Health Status Review

C. Muscular Dystrophy ❑ Yes

❑ Never

D. Amyotrophic Lateral Sclerosis(Lou Gehrig’s
disease)? ❑ Yes ❑ Never
E. Narcolepsy? ❑ Yes

❑ Never

79. Do you have or have you ever had any other
neurological or nervous system condition or
surgery not listed in items 75-77? ❑ Yes ❑ Never
If yes, please specify:

A. Cerebral Palsy?
❑ Yes ❑ Never
B. Multiple Sclerosis? ❑ Yes

78. Continued:

❑ Never

_______________________________________________
_____________________________________________

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ONCOLOGY
80. Do you have or have you ever had:
A. Leukemia or lymphoma?

❑ Yes

❑ No

B. Any other type of cancer or malignant tumor not previously noted on this form? ❑ Yes

❑ No

PSYCHOLOGY/MENTAL HEALTH
85. Have you been told you have Depression?

81. Are you:
A. Recovered or recovering from alcohol abuse/
dependence? ❑ Yes ❑ No
B. If yes, give start date of sobriety.
______/_______/_________
Month

Day

Year

C. If yes, do you rely on AA to maintain sobriety?
❑ Yes ❑ No
D. Recovered or recovering from substance abuse/
dependence?
❑ Yes ❑ Never
E If yes, give start date of abstinence
______/_______/_________
Month

Day

Year

F. If yes, do you rely on NA to maintain abstinence
❑ Yes ❑ No
82. Have you ever been told that you have or have
had a medical condition caused by excessive
alcohol or drug use? ❑ Yes ❑ Never
If yes, please specify:
______________________________________________
______________________________________________

❑ Yes

❑ Never

86. Have you been told you have Anxiety?
❑ Yes

❑ Never

87. Have you been told you have Panic Attacks?
❑ Yes

❑ Never

88. Do you use medication(s) for a mental health
issue?: (Mark resolved if you no longer take medications)
❑ Yes
❑ Resolved
❑ Never
B If resolved, give date of most recent use of
medication.
______/_______/_________
Month

Day

Year

89. Have you ever received in-patient psychiatric
care? ❑ Yes
❑ Never
B If yes, give date of last in-patient psychiatric care.
______/_______/_________
Month

Day

Year

90. Have you ever tried to harm yourself or
attempted suicide? ❑ Yes
❑ Never
B If yes, give date of incident
______/_______/_________
Month

Day

Year

91. Have you ever been diagnosed with, had
symptoms of, or been treated for an eating
disorder? ❑ Yes
❑ Never
83. Have you ever had:
A. Family counseling (such as related to marital
issues)? ❑ Yes ❑ Never
B. Support group counseling (such as for grief or
divorce)?
❑ Yes ❑ Never
84. Other than counseling for academic guidance,
an eating disorder, or ADD/ADHD, have you ever
had:
A. Individual counseling or consultation with a
psychiatrist, psychologist or mental health
counselor?
❑ Yes ❑ Never
B. If yes, give date of last counseling session?
______/_______/_________
Month

Day

Year

C. Substance abuse or alcohol abuse counseling?
❑ Yes ❑ Never
D. If yes, give date of last counseling session?
______/_______/_________
Month

Day

B If yes, give date of last symptoms, treatment, or
support group participation.
______/_______/_________
Month

Day

Year

92. Have you ever been diagnosed with, or had
symptoms of ADD/ADHD?: (Mark resolved if you no
longer see a physician regarding this condition and/or no longer
have symptoms)

❑ Yes

❑ Resolved

❑ Never

B If resolved, give date of resolution.
______/_______/_________
Month

Day

Year

93. Are you currently using or have you ever used
medication for ADD/ADHD? ❑ Yes
❑ Never
B If yes, give date of last treatment?
______/_______/_________
Month

Day

Year

Year

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PSYCHOLOGY/MENTAL HEALTH CONTINUED
94. Do you have or have you ever had any other mental health condition not listed in items 81-93 ?
❑ Yes ❑ No
If yes, please specify:
________________________________________________________________________________________________________
________________________________________________________________________________________________________

ACTIVITIES OF DAILY LIVING
95. Does walking 2 blocks on flat terrain cause you
to experience shortness of breath, leg, joint,
muscle or chest pain?
❑ Yes

❑ No

96. Does climbing 2 flights of stairs carrying
groceries or other items cause you to
experience shortness of breath, leg, joint,
muscle or chest pain?
❑ Yes

❑ No

97. Does kneeling, squatting or sitting cross-legged
cause you shortness of breath, leg, joint, muscle
or chest pain?
❑ Yes

❑ No

98. Do you use prosthesis or other assistive device,
e.g. wheelchair, walker, cane, leg braces,
❑ No
hearing aid(s)? ❑ Yes
99. Do you have or have you been told that you
have any hearing or speech condition that might
affect your ability to communicate?
❑ Yes
❑ No

100. Do you require assistance with routine activities
such as walking, dressing, bathing, shopping or
cooking?
❑ Yes
❑ No
101. Does anything prohibit you from living and
working in hot, cold, humid or dry climates, or in
polluted environments? (This refers to your ability to work
and live in these environments, NOT your personal preferences)

❑ Yes

❑ No

102. Does anything prohibit you from living and
working in high altitudes, such as above 5,000
feet? ❑ Yes
❑ No
103. Do you have or have you ever had any other
medical condition(s) that could impact your
ability to provide 27 months of service?
❑ Yes
❑ No
If yes, please specify:
______________________________________________
______________________________________________

I CERTIFY that all of the above information is true, correct and complete. I understand that providing misleading,
inaccurate, or incomplete information will delay processing my application and may be cause for disqualification (result
in withdrawal of my Peace Corps nomination or invitation) or in termination from Peace Corps service. In addition, any
intentionally false statement (or intentional omission of information) may be subject to fines and/or imprisonment pursuant
to 18 U.S.C. § 1001.
I understand that it is my responsibility throughout the application process to inform the Peace Corps Office of Medical
Services of any changes to the information provided here, and to keep them updated on any other changes to my medical
status.

______________________________________________________________________________________________________

Signature Date

Peace Corps – Health Status Review

PC-1789

3/2010