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Peace Corps
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Health Histor
Introduction
The Peace Corps needs to assess your overall health status before you can be accepted to serve
overseas. The health history is the first step in the medical review process, which will take about an
hour to complete. Your signature at the end of the questionnaire certifies that you have answered all
questions accurately and completely.
A Medical Histor
Placement
for International
A health condition you manage easily at home in the U.S. can become a significant medical issue in
many countries where Peace Corps Volunteers serve. The Peace Corps Office of Medical Services
assesses your health in the context of living conditions and medical care in each country.
For this reason, the types of medical questions and the level of detail required are unlike other medical
histories you might normally be asked.
The Applicant Medical Screening Process is thorough, and it is important for you to answer all
questions accurately. On average, Peace Corps is able medically clear more than 85% of all
applicants.
Privac Act Notice
This information is collected under the authority of the Peace Corps Act, 22 U.S.C. 2501 et seq. It will be
used primarily for the purpose of determining your eligibility for Peace Corps service and, if you are
invited to serve as a Peace Corps Volunteer, for the purpose of providing you with medical care during
your Peace Corps service. Your disclosure of this information is voluntary; however, your failure to
provide this information will result in the rejection of your application to become a Peace Corps
Volunteer.
This information may be used for the purposes described in the Privacy Act, 5 USC 552a, including the
routine uses listed in the Peace Corps System of Records. Among other uses, this information may be
used by those Peace Corps staff who have a need for such information in the performance of their
duties. It may also be disclosed to the Office of Workers Compensation Programs in the Department of
Labor in connection with claims under the Federal Employees Compensation Act and, when
necessary, to a physician, psychiatrist, clinical psychologist or other medical personnel treating you or
involved in your treatment or care. A full list of routine uses for this information can be found on the
Peace Corps website at http://multimedia.peacecorps.gov/multimedia/pdf/policies/systemofrecords.pdf
.
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B rden S a emen
Public reporting burden for this collection of information is estimated to average 45 minutes per
response. This estimate includes the time for reviewing instructions and completing the collection of
information. An agenc ma not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displa s a currentl valid OMB control number. Send comments
regarding this burden estimate or an other aspect of this collection of information, including
suggestions for reducing this burden, to: FOIA Officer, Peace Corps, 1111 20th Street, NW, Washington,
DC 20526 ATTN: PRA (0420-####). Do not return the completed form to this address.
Con in e
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Peace Corps
Welcome ekehne Log Off
Home
Authori ation for Peace Corps Use of
Medical Information
(please print and keep this for our records)
WHY IS THE PEACE CORPS ASKING ME TO SIGN THIS
AUTHORIZATION?
HIPAA — the Health Insurance Portability and Accountability Act — is a federal law which, together with
related regulations, is designed in part to protect informa¬tion about your health from unreasonable
disclosure. It limits the extent to which your “protected health information” — individually identifiable
information about your physical or mental health or the health care you have received — can be used
without your consent for purposes other than medical treatment and payment, and related business
operations. Since the Peace Corps provides medical care to Peace Corps Volunteers during their
service, it is subject to HIPAA requirements. HIPAA requires individuals to be given a notice describing
how medical professionals and health plans use their medical information. The Peace Corps notice is
available on its website at www.peacecorps.gov/policies/pdf/hipaa.pdf
Since Peace Corps Volunteers often live and work in remote areas with less sophisticated sanitation
and health-care networks, and higher levels of endemic diseases, than are typical in the United States,
all applicants must receive medical clearance before joining the Peace Corps. Your medical status
may also have a bearing on the location of your Peace Corps assignment. The Peace Corps needs
access to information about your medical history and current medical condition, including the answers
you provide on this Health History Form and other information collected during the Peace Corps
medical clearance process, to determine whether you are medically eligible for Peace Corps service
and, if so, where you will be placed as a Volunteer.
Because HIPAA puts strict limits on the use of your protected health information, the Peace Corps must
have a signed authorization from you to use that information for purposes other than medical treatment
and payment. Therefore, unless ou sign this authori ation, the Peace Corps will not be able to
consider our application for Peace Corps service.
In addition, if you are offered and accept an invitation to become a Peace Corps Volunteer, the
information collected during the medical clearance process will become part of your Peace Corps
medical record. The Peace Corps medical staff will add information to your medical record as they care
for you. As a Peace Corps Volunteer, the Peace Corps will be responsible for your medical care and
Peace Corps medical staff will, as permitted by HIPAA, use your health information for medical
treatment and payment. However, the Peace Corps has other responsibilities, including training
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Volunteers, 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. There
may, therefore, be situations in which Peace Corps non-medical staff need your health information for
purposes other than medical treatment or payment.
Under the Peace Corps medical confidentiality policy, your health informa¬tion may be disclosed to
Peace Corps non-medical staff only if they have a specific need to know the information to do their
jobs. This might include situations in which the Country Director at your post needs medically
confidential information in order to manage the post. Only the minimum amount of information
necessary will be disclosed and recipients are required to protect the confidentiality of the health
information they receive.
The following are some specific examples of health information that may be disclosed to Peace Corps
non-medical staff if they have a specific need to know the information to do their jobs:
e ide ce
f i ega
he e i e ce
i h he
i f
a
a i
he
i f
e
a i
ab
i
he fac
i f
a i
ha
di i
f
ha e bee
e
a
he
e
da i
,a
g
;
hea h
ih
afe
ha
edica ad ice
fa
h
ica
e a a ge e
di i
i e acc
fa
icie
ha
e a
e e e;
he ic i
e
edica c
e
hich
ia ce
e
eeded
e;
h ea
-c
ab
g
da i
a e i
f ha
fa
a i
i ed d
f he acc
ha
a i
h
edica c
ea i g
;
i f
i f
fa
e
e i
a
if eeded
f
e
e
a a
a
edica e ac a i
a
e
;
afe
;
a d ec
i
;
ab
a
edica c
ab
i
e
di i
ha i affec i g
e f
a ce
e -
bei g;
i f
a i
e e a
i f
e i
a i
edica i f
i
he beha i
ha i
i g
e
e
;a d
ea i g
a i
a
i i
fa
he Peace C
d
i eadi g, i acc
i g he a
ica i
a e
ce
i c
e e
.
You may revoke this authorization at any time. However, because this authori ation is needed in order
for the Peace Corps to administer its program, ou ma continue to serve as a Volunteer onl for as
long as this authori ation remains in effect.
Thi a h i a i
e i
he Peace C
e
ec ed hea h i f
a i
de e i e
e igibi i f
he Peace C
a da
ece a f ad i i a i
f he
Peace C
g a .I
de a d ha this document must be signed, dated, and
returned with m medical information, and that the Peace Corps will be unable to
review m information without this signed document.
I, E i abe h Keh e he eb a h i e ha :
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 History form, and any follow-up health information requested by and provided to the Peace
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Co p Office of Vol n ee S ppo
(incl ding b
heal h
a
ela ing o me p io o m being
no limi ed o info ma ion abo
, and po
Peace Co p
ible f
m p io ph
o n in a a Peace Co p Vol n ee
ical and men al heal h hi o , m c
en
e ca e and ea men ), ma be di clo ed o he follo ing people:
aff, incl ding in he Office of Vol n ee S ppo , Office of Vol n ee Rec i men
Selec ion, Office of Global Ope a ion , Office of Safe and Sec i , Office of Gene al Co n el, , Peace
Co p Medical Office , Co n
con ac o
Di ec o
a o e ea po
ho ha e a pecific need o kno
, and an o he Peace Co p
he info ma ion o pe fo m hei d ie , fo he p po e
of making a de e mina ion of m medical o o he eligibili fo Peace Co p
placemen /a
aff o
e ice and of
ignmen .
B. If I am accep ed fo Peace Co p
e ice, he info ma ion li ed abo e
ill become pa of m Peace
Co p heal h eco d. All info ma ion in m Peace Co p heal h eco d, and an o he pe onal heal h
info ma ion ele an o me ha i p o ided o he Peace Co p b me o an heal h ca e p o ide o
o he pe on, ma be di clo ed o Peace Co p
abo e, ho ha e a pecific need o kno
connec ion
i h admini
aff o con ac o , a de c ibed in pa ag aph A
he info ma ion fo he p po e of pe fo ming hei d ie in
a ion of he Peace Co p p og am onl . Thi ma incl de (b
info ma ion ele an o m con in ed e ice a a Peace Co p
Thi a ho i a ion i effec i e n il fi e ea
de e mina ion b he Peace Co p
follo ing ei he m clo e of Peace Co p
ha I am no eligible fo Peace Co p
e oke hi a ho i a ion a an ime b
ending a
op con ide a ion of m applica ion, and ha m
e i ence of hi a ho i a ion, hich i nece
I al o nde
a
e ice o final
e ice. I nde
and ha I ma
i en e oca ion o he Office of Vol n ee S ppo ,
Peace Co p , 1111 20 h S ee , NW, Wa hing on DC, 20526, b
ill
i no limi ed o)
ainee o Peace Co p Vol n ee .
ha m
e oca ion befo e accep ance
e ice a a Vol n ee i condi ioned on he
o admini e he Peace Co p p og am.
and ha d ing he en i e pe iod of hi a ho i a ion o
e m heal h ca e info ma ion,
Peace Co p
ill p o ec he confiden iali of m heal h ca e info ma ion, con i en
i h he P i ac Ac ,
he Heal h In
ance Po abili and Acco n abili Ac (a applicable), and Peace Co p policie on
confiden iali of medical info ma ion, a de c ibed in he Peace Co p No ice of P i ac P ac ice and
Peace Co p Man al Sec ion 268.
I ha e ead and nde
Signa
re:
and hi a ho i a ion.
Eli abeth Kehne
Eli abeth Kehne
Da e of Bir h: 01/01/1970
Submit
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OPENING QUESTIONS
Si emap
I
d ci
HIPAA Sig a
e
O e i gQ e i
A e g
Ca di a c a
De a
g
E d ci
g
Ea , N e, Th a
Ga
e e
g
Rhe
a
g a d
I
g
Ne
g
M c
ee a
I fec i
Di ea e
He a
g
G aec
g
Re i a
U
g a d
Ne h
g
O ha
g
Me a Hea h
C
i gQ e i
Diag
e
Ve ifica i
Sig a
e
H
a a e
H
ch d
? (Heigh i i che ) 65
eigh? (Weigh i
d )
120
C
Ha e
bef
e e fi ed
e?
a Hea h Hi
Q e
i
ai e f
he Peace
Yea :
1999
I ha e bee
Da e
diag
f diag
ed
i h ca ce ( f a
i :
T
Februar , 2012
Add a
e
e) i
ife i e
f Ca ce
De e e
Skin
i cide
f ca ce
Chec a ea
e
i
be
:
M Ca ce
ea e i c
e e
I i ecei e ea e
e a ed
T
hi Ca ce diag
i
e:
N/A
Da e
f La
T ea
e
Januar 2012
Chec a ea
e
i
be
:
I
ge ee a
hea h ca e
ide i
ca ce diag
i
If
e i dica
i h a hea h ca e
ea i
hi ca ce diag
i
Ne
e
ea i
hi
ide i
ec ed i i da e d e)
Januar 2012
I ha e e i dic ab
Ca ce diag
i
Li
e
f e
a
,f e
diag
ic e
i gd e
hi
e c
/A
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REPORT OF CURRENT MEDICATIONS
Do ou take an prescription medications?
Please list all medications ou are currentl taking. If ou do
not know a start date or strength of a medication, please
answer "unknown".
Medication (Name): N/A
Route: Oral
Start Date: Januar 2012
Strength (e.g., 50 mg): N/A
Frequenc (e.g., ever da or as needed):
N/A
Delete Medication
Add a Medication
Do ou regularl take an over the counter medications or herbal
remedies?
Please list all medications ou are currentl taking. If ou do
not know a start date or strength of a medication or remed ,
please answer "unknown".
Medication (Name): N/A
Route: Oral
Start Date: Januar 2012
Strength (e.g., 50 mg): N/A
Frequenc (e.g., ever da or as needed):
N/A
Delete Medication
Add a Medication
Has our doctor changed our medication or have ou stopped taking a
medication in the last 6 months?
Please list each medication that was changed or that ou
stopped taking and the reason the medication regime was
changed or stopped
/A
REPORT OF PH SICAL ABILITIES
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Peace C
V
ca i
ih
e
h
i
ee
e
de e
deci i
a be a dai
ie
a
e i g
e e h
hea
e
abi i
a a
ha
a i c de e
i e c i bi g
ee ,
ae i
ai
a
a
a
ea
ai
idi i c
da e
ad ,
e ea
a
e i
,a d
ih
gh
ai
c
di i
a i g
a i g
ih
. The
ch c
e
i ef
i i ed a d
c d. Ice a d
i eh
acc
ie
ha e
.T a
gged e ai ,
d
c
e i e acce
ea he ha i e
i e
di i
ci
i g g ce ie . S
f ae
bi i g
e ei c
gged e ai
hi e ca
b c e
ee
a e
d
ih
be
ae
ed
ace e
ia e.
Check all that apply: (if you mark cannot , a description is
required)
I ca
I ca
a
di a ce
a di a ce
gh
I ca c i b a ea 2 f igh
f
ih
diffic
I ca
c i b a ea 2 f igh
ih
diffic
I ca
I ca
ide a bic c e
ide a bic c e
I ca
I ca
ide a bic c e
ide a bic c e
ca
f
gh
ai
h da
a i g
ii
f
h da
a i g
ii
I ca
I ca
if (chec he highe
if a ea 10
20
d
50
d
ca
gh
f
ca
ggage
ce ie
ggage
ad
gh ad
hich
ca if
diffic
ca
e a e i i g i c di i
(chec a
Hea > 90 deg ee
C d < 20 deg ee
a D
If a
ce ie
i gg
e e a
i
e e a
eigh
d
ih
eigh
i gg
ad
gh ad
I ca
I ca
P ea e chec a
10
d
C
ai
e a e idi g i a ehic e
e a e idi g i a ehic e
I ca
I ca
I ca
e e e ai
e e e ai
gh
e
i
e
ih
diffic
)
if
ha a
C
f he ab e b e a e chec ed,
i e i h e e i
e
:
)
a
Da
ea e de c ibe
e
h
/A
I ca
I ca
I ha
i i
I ha
dai i i
dai
map.peaceco p .go /MAP/HHF/OpeningQ e ion /Edi
e a e i i g a a a i de 5000 fee ab e ea e e
e a e i i g a a a i de 5000 fee ab e ea e e
e
g.
e
g.
i ia i
e i ia i
f
ci
f
a abi i ie
ci
a abi i ie
ee
ac i i ie
ee
ac i i ie
f
f
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ALLERGY
(Conditions of Allergic Response)
Allerg Shots
E
Ic e
ecei e a e g
h
ec ed da e f a
ea e
Februar 2012
Life Threatening Reactions
I m lifetime I ha e e e ie ced a life threatening allergic reaction i h
e
a
f he e
mouth,tongue, lips and/or difficult breathing, loss of cosciousness, and/or severe drop in blood pressur
A e ge
De c ibe
N/A
N/A
Add a
M
Da e:
a e g
eac i
e
i ed a
eac i
Da e
f a
eac i
Januar 2012
E e ge c R
i i
H
iai a i
Januar 2012
I i eed
ecia
De c ibe
eac i
ace e
d e
a e gic eac i
hi a e ge
/A
P ea e e
H
d
d e
a
f he b
hi c
Wha i
a
De c ibe
e
D
C
ha e a
? If
,
e
di i
be
affec
f
.
ac i i ie
f dai
a agi g a
e
c
i
ce
a
ea
e a ed
i i g/
hi e e
e
e c ibed f
hi c
di i
ha
i g
?
i h he Peace C
hi c
di i
a i
ac
?
.
abi i
e
e 27
ea e de c ibe.
/A
CHECK ALL ALLERGIES YOU HAVE:
Food Allergens
Pea
map.peacecorps.gov/MAP/HHF/Allerg /Edit
N
A e g
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A e ge
De c ibe
N/A
N/A
Add a a e g
If I e e ie ce a eac i
Li
eac i
Da e
f a
eac i
Januar 2012
,
ea
e
e
e ie ce a eac i
,
ea
e
e ie ce a eac i
, I ha e E i-Pe
ie
he
e
f
e - he-c
e
edica
/A
If I e
e
ie a
e ci
i
Li
/A
If I e
P ea e e
H
d
d e
a
f he b
hi c
Wha i
a
De c ibe
e
D
e
di i
c
ac i i ie
a
e
.
f dai
a agi g a
e
ha e a
be
affec
f
i h he Peace C
i
e c ibed f
i i g/
hi e e
ea
e
ce
e a ed
? If
,
e c ibed f
hi c
di i
?
i g
i h he Peace C
hi c
di i
ha
a i
ac
he
e
e - he-c
?
.
abi i
e
ea e de c ibe.
/A
She fi h A e g
De c ibe
eac i
/A
Da e
f a
eac i
Januar 2012
If I e
e ie ce a eac i
,
ea
e
e
e ie ce a eac i
,
ea
e
e ie ce a eac i
, I ha e E i-Pe
ie
f
e
edica
Li
/A
If I e
e
ie a
e ci
i
Li
/A
If I e
P ea e e
H
map.peacecorps.gov/MAP/HHF/Allerg /Edit
d
d e
a
f he b
hi c
Wha i
a
De c ibe
e
e
di i
f
i
be
affec
a
ea
e
.
ac i i ie
a agi g a
e
e c ibed f
f dai
i i g/
hi e e
e
e c ibed f
i g
hi c
?
i h he Peace C
di i
?
.
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D
ha e a
c
i h he Peace C
ce
e a ed
? If
,
hi c
di i
ha
a i
ac
abi i
he
e
e - he-c
e
ea e de c ibe.
/A
Egg
Egg P
ei A e g
De c ibe
eac i
/A
Da e
f a
eac i
Januar 2012
If I e
e ie ce a eac i
,
ea
e
e
e ie ce a eac i
,
ea
e
e ie ce a eac i
, I ha e E i-Pe
ie
f
e
edica
Li
/A
If I e
e
ie a
e ci
i
Li
/A
If I e
P ea e e
H
d
d e
a
f he b
hi c
Wha i
a
De c ibe
e
D
ha e a
e
di i
ac i i ie
a
e
.
f dai
a agi g a
e
c
be
affec
f
i h he Peace C
i
e c ibed f
i i g/
hi e e
ea
e
ce
e a ed
? If
,
e c ibed f
hi c
di i
ha
?
i g
i h he Peace C
hi c
di i
a i
ac
?
.
abi i
e
ea e de c ibe.
/A
Mi
Dai
A e g
A e ge
De c ibe
N/A
N/A
Add a a e g
If I e e ie ce a eac i
Li
map.peacecorps.gov/MAP/HHF/Allerg /Edit
,
ea
eac i
Da e
f a
eac i
Januar 2012
e
e
ie
he
e
f
e - he-c
e
edica
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/A
If I e
e ie ce a eac i
,
ea
e
e
e ie ce a eac i
, I ha e E i-Pe
ie a
e ci
i
Li
/A
If I e
P ea e e
H
d
d e
a
f he b
hi c
Wha i
a
De c ibe
e
D
e
di i
c
ac i i ie
a
e
.
f dai
a agi g a
e
ha e a
be
affec
f
i h he Peace C
i
e c ibed f
i i g/
hi e e
ea
e
ce
e a ed
? If
,
e c ibed f
hi c
di i
ha
?
i g
i h he Peace C
hi c
di i
a i
ac
?
.
abi i
e
ea e de c ibe.
/A
O he F
d A e gie
A e ge
De c ibe
N/A
N/A
Add a a e g
If I e e ie ce a eac i
Li
eac i
Da e
f a
eac i
Januar 2012
,
ea
e
e
e ie ce a eac i
,
ea
e
e ie ce a eac i
, I ha e E i-Pe
ie
he
e
f
e - he-c
e
edica
/A
If I e
e
ie a
e ci
i
Li
/A
If I e
P ea e e
H
d
d e
a
f he b
hi c
Wha i
a
De c ibe
e
D
ha e a
i h he Peace C
e
di i
be
affec
f
a
ac i i ie
ea
ce
e a ed
? If
,
e
.
f dai
a agi g a
e
c
i
e c ibed f
i i g/
hi e e
e
e c ibed f
hi c
di i
ha
i g
?
i h he Peace C
hi c
di i
a i
ac
?
.
abi i
ea e de c ibe.
/A
map.peacecorps.gov/MAP/HHF/Allerg /Edit
4/14
e
1/18/12
map.peacecorps.gov/MAP/HHF/Allerg /Edit
Pe ici i A e g
De c ibe
eac i
/A
Da e
f a
eac i
Januar 2012
If I e
e ie ce a eac i
,
ea
e
e
e ie ce a eac i
,
ea
e
e ie ce a eac i
, I ha e E i-Pe
ie
he
e
f
e - he-c
e
edica
Li
/A
If I e
e
ie a
e ci
i
Li
/A
If I e
P ea e e
H
d
d e
a
f he b
hi c
Wha i
a
De c ibe
e
D
ha e a
e
di i
ac i i ie
a
e
.
f dai
a agi g a
e
c
be
affec
f
i h he Peace C
i
e c ibed f
i i g/
hi e e
ea
e
ce
e a ed
? If
,
e c ibed f
hi c
di i
?
i g
i h he Peace C
hi c
di i
ha
a i
ac
he
e
e - he-c
?
.
abi i
e
ea e de c ibe.
/A
Medica ion Alle gen
S fa A e g
De c ibe
eac i
/A
Da e
f a
eac i
Januar 2012
If I e
e ie ce a eac i
,
ea
e
e
ie
f
e
edica
Li
/A
map.peacecorps.gov/MAP/HHF/Allerg /Edit
5/14
1/18/12
map.peacecorps.gov/MAP/HHF/Allerg /Edit
If I e
e ie ce a eac i
,
ea
e
e
e ie ce a eac i
, I ha e E i-Pe
ie a
e ci
i
Li
/A
If I e
P ea e e
H
d
d e
a
f he b
hi c
Wha i
a
De c ibe
e
D
e
di i
c
ac i i ie
a
e
.
f dai
a agi g a
e
ha e a
be
affec
f
i h he Peace C
i
e c ibed f
i i g/
hi e e
ea
e
ce
e a ed
? If
,
e c ibed f
hi c
di i
?
i g
i h he Peace C
hi c
di i
ha
a i
ac
he
e
e - he-c
?
.
abi i
e
ea e de c ibe.
/A
Te ac c i e A e g
De c ibe
eac i
/A
Da e
f a
eac i
Januar 2012
If I e
e ie ce a eac i
,
ea
e
e
e ie ce a eac i
,
ea
e
e ie ce a eac i
, I ha e E i-Pe
ie
f
e
edica
Li
/A
If I e
e
ie a
e ci
i
Li
/A
If I e
P ea e e
H
d
d e
a
f he b
hi c
Wha i
a
De c ibe
e
D
ha e a
i h he Peace C
e
di i
be
affec
f
a
ac i i ie
ea
ce
e a ed
? If
,
e
.
f dai
a agi g a
e
c
i
e c ibed f
i i g/
hi e e
e
e c ibed f
hi c
di i
ha
i g
?
i h he Peace C
hi c
di i
a i
ac
?
.
abi i
ea e de c ibe.
/A
map.peacecorps.gov/MAP/HHF/Allerg /Edit
6/14
e
1/18/12
map.peacecorps.gov/MAP/HHF/Allerg /Edit
O he
edica i
A e g (ie )
A e ge
De c ibe
N/A
N/A
Add a a e g
If I e e ie ce a eac i
Li
eac i
Da e
f a
eac i
Januar 2012
,
ea
e
e
e ie ce a eac i
,
ea
e
e ie ce a eac i
, I ha e E i-Pe
ie
he
e
f
e - he-c
e
edica
/A
If I e
e
ie a
e ci
i
Li
/A
If I e
P ea e e
H
d
d e
a
f he b
hi c
Wha i
a
De c ibe
e
D
e
di i
c
ac i i ie
a
ea
ce
e a ed
? If
,
e
.
f dai
a agi g a
e
ha e a
be
affec
f
i h he Peace C
i
e c ibed f
i i g/
hi e e
e
e c ibed f
hi c
di i
ha
i g
?
i h he Peace C
hi c
di i
a i
ac
?
.
abi i
e
ea e de c ibe.
/A
Ia
(c
a e gic
h ee
e e hi ec i
i f
I ca
cce f
hi e i Peace C
e
e
e e if
a e,
.
ih
f a ibi ic .
ha e a ead e
a
ed a
a e gic eac i
a e gic eac i
he f
i ga
ibi
).
ic , h
d I de e
/A
Id
ha a
P ea e e
H
d
d e
a
f he b
hi c
Wha i
a
De c ibe
e
D
ibi
ha e a
i h he Peace C
di i
afe
a e
e
be
.
i
affec
f
ac i i ie
f dai
a agi g a
e
c
ic I ca
a
ea
ce
e a ed
? If
,
i i g/
hi e e
e
e c ibed f
hi c
di i
ha
i g
?
i h he Peace C
hi c
di i
a i
ac
?
.
abi i
ea e de c ibe.
/A
map.peacecorps.gov/MAP/HHF/Allerg /Edit
7/14
e
1/18/12
map.peacecorps.gov/MAP/HHF/Allerg /Edit
Animal Alle gen
Bee
Wa
A e g
De c ibe
eac i
Da e
N/A
f a
eac i
De e e
Januar 2012
Add a a e g
If I e e ie ce a eac i
Li
,
ea
e
e
e ie ce a eac i
,
ea
e
e ie ce a eac i
, I ha e E i-Pe
ie
he
e
f
e - he-c
e
edica
/A
If I e
e
ie a
e ci
i
Li
/A
If I e
P ea e e
H
d
d e
a
f he b
hi c
Wha i
a
De c ibe
e
D
ha e a
e
di i
ac i i ie
a
e
.
f dai
a agi g a
e
c
be
affec
f
i h he Peace C
i
e c ibed f
i i g/
hi e e
ea
e
ce
e a ed
? If
,
e c ibed f
hi c
di i
?
i g
i h he Peace C
hi c
di i
ha
a i
ac
he
e
e - he-c
?
.
abi i
e
ea e de c ibe.
/A
Ca A e g
De c ibe
eac i
/A
Da e
f a
eac i
Januar 2012
If I e
e ie ce a eac i
,
ea
e
e ie ce a eac i
,
ea
e
e
ie
f
e
edica
Li
/A
If I e
e
ie a
e ci
i
Li
map.peacecorps.gov/MAP/HHF/Allerg /Edit
8/14
1/18/12
map.peacecorps.gov/MAP/HHF/Allerg /Edit
/A
If I e
e ie ce a eac i
P ea e e
H
d
d e
a
f he b
hi c
Wha i
a
De c ibe
e
D
, I ha e E i-Pe
e
di i
c
ac i i ie
a
e
.
f dai
a agi g a
e
ha e a
be
affec
f
i h he Peace C
i
e c ibed f
i i g/
hi e e
ea
e
ce
e a ed
? If
,
e c ibed f
hi c
di i
?
i g
i h he Peace C
hi c
di i
ha
a i
ac
he
e
e - he-c
?
.
abi i
e
ea e de c ibe.
/A
D gA e g
De c ibe
eac i
/A
Da e
f a
eac i
Januar 2012
If I e
e ie ce a eac i
,
ea
e
e
e ie ce a eac i
,
ea
e
e ie ce a eac i
, I ha e E i-Pe
ie
f
e
edica
Li
/A
If I e
e
ie a
e ci
i
Li
/A
If I e
P ea e e
H
d
d e
a
f he b
hi c
Wha i
a
De c ibe
e
D
ha e a
i h he Peace C
e
di i
be
affec
f
a
ac i i ie
ea
ce
e a ed
? If
,
e
.
f dai
a agi g a
e
c
i
e c ibed f
i i g/
hi e e
e
e c ibed f
hi c
di i
ha
i g
?
i h he Peace C
hi c
di i
a i
ac
?
.
abi i
ea e de c ibe.
/A
O he A i a A e g (ie )
map.peacecorps.gov/MAP/HHF/Allerg /Edit
9/14
e
1/18/12
map.peacecorps.gov/MAP/HHF/Allerg /Edit
A e ge
De c ibe
N/A
N/A
Add a a e g
If I e e ie ce a eac i
Li
eac i
Da e
f a
eac i
Januar 2012
,
ea
e
e
e ie ce a eac i
,
ea
e
e ie ce a eac i
, I ha e E i-Pe
ie
he
e
f
e - he-c
e
edica
/A
If I e
e
ie a
e ci
i
Li
/A
If I e
P ea e e
H
d
d e
a
f he b
hi c
Wha i
a
De c ibe
e
D
ha e a
e
di i
ac i i ie
a
e
.
f dai
a agi g a
e
c
be
affec
f
i h he Peace C
i
e c ibed f
i i g/
hi e e
ea
e
ce
e a ed
? If
,
e c ibed f
hi c
di i
?
i g
i h he Peace C
hi c
di i
ha
a i
ac
he
e
e - he-c
?
.
abi i
e
ea e de c ibe.
/A
En ironmental Allergens
D
A e g
De c ibe
eac i
/A
Da e
f a
eac i
Januar 2012
If I e
e ie ce a eac i
,
ea
e
e ie ce a eac i
,
ea
e
e
ie
f
e
edica
Li
/A
If I e
e
ie a
e ci
i
Li
/A
map.peacecorps.gov/MAP/HHF/Allerg /Edit
10/14
1/18/12
map.peacecorps.gov/MAP/HHF/Allerg /Edit
If I e
e ie ce a eac i
P ea e e
H
d
a
d e
f he b
hi c
Wha i
a
De c ibe
e
D
, I ha e E i-Pe
e
di i
be
affec
f
ac i i ie
c
i h he Peace C
a
e
.
f dai
a agi g a
e
ha e a
i
e c ibed f
i i g/
hi e e
ea
e
ce
e a ed
? If
,
e c ibed f
hi c
di i
?
i g
i h he Peace C
hi c
di i
ha
a i
ac
he
e
e - he-c
?
.
abi i
e
ea e de c ibe.
/A
M dA e g
De c ibe
eac i
/A
Da e
f a
eac i
Januar 2012
If I e
e ie ce a eac i
,
ea
e
e
e ie ce a eac i
,
ea
e
e ie ce a eac i
, I ha e E i-Pe
ie
f
e
edica
Li
/A
If I e
e
ie a
e ci
i
Li
/A
If I e
P ea e e
H
d
a
d e
f he b
hi c
Wha i
a
De c ibe
e
D
ha e a
i h he Peace C
e
di i
be
affec
f
a
ac i i ie
ea
ce
e a ed
? If
,
e
.
f dai
a agi g a
e
c
i
e c ibed f
i i g/
hi e e
e
e c ibed f
hi c
di i
ha
i g
?
i h he Peace C
hi c
di i
a i
ac
?
.
abi i
ea e de c ibe.
/A
Sea
a A e g (P
e , T ee , e c.)
I ha e/had
S
map.peacecorps.gov/MAP/HHF/Allerg /Edit
d e
hi c
di i
(
ch a
ee i g,i ch e e )
: N/A
11/14
e
1/18/12
map.peacecorps.gov/MAP/HHF/Allerg /Edit
D e hi
Se e i :
affec
dai
ife?
Mild
F e
e c :
Dail
Da e
I
f a
hi a
cc
e ce: Januar 2012
g i g
?:
De e e
Add a
I e ie
Medica i
edica i
ei he dail or as needed f
hi c
di i
/A
If I e
e ie ce a eac i
P ea e e
H
d
d e
a
f he b
hi c
Wha i
a
De c ibe
e
D
, I ha e E i-Pe
e
di i
c
ac i i ie
a
e
.
f dai
a agi g a
e
ha e a
be
affec
f
i h he Peace C
i
e c ibed f
i i g/
hi e e
ea
e
ce
e a ed
? If
,
e c ibed f
hi c
di i
ha
?
i g
i h he Peace C
hi c
di i
a i
ac
?
.
abi i
e
ea e de c ibe.
/A
O he E
i
e
A e g (ie )
e i
i ed
A e ge
De c ibe
N/A
N/A
Add a a e g
If I e e ie ce a eac i
Li
eac i
Da e
f a
eac i
Januar 2012
,
ea
e
e
e ie ce a eac i
,
ea
e
e ie ce a eac i
, I ha e E i-Pe
ie
he
e
f
e - he-c
e
edica
/A
If I e
e
ie a
e ci
i
Li
/A
If I e
P ea e e
H
d e
a
f he b
hi c
Wha i
a
De c ibe
e
D
map.peacecorps.gov/MAP/HHF/Allerg /Edit
d
ha e a
e
di i
be
affec
f
ce
a
ac i i ie
ea
e a ed
e
.
f dai
a agi g a
e
c
i
e c ibed f
i i g/
hi e e
e
e c ibed f
hi c
di i
ha
i g
?
i h he Peace C
hi c
di i
a i
ac
?
.
abi i
12/14
e
1/18/12
map.peacecorps.gov/MAP/HHF/Allerg /Edit
i h he Peace C
? If
,
ea e de c ibe.
/A
Other Allergens
O he A e g (ie )
Sitemap
I
d ci
HIPAA Sig a
e
O e i gQ e i
A e g
Ca di a c a
De a
g
E d ci
g
Ea , N e, Th a
Ga
e e
g
Rhe
a
g a d
I
g
Ne
g
M c
ee a
I fec i
Di ea e
He a
g
G aec
g
Re i a
U
g a d
Ne h
g
O ha
g
Me a Hea h
C
i gQ e i
Diag
e
Ve ifica i
Sig a
e
e i
i ed
A e ge
De c ibe
N/A
N/A
Add a a e g
If I e e ie ce a eac i
Li
Da e
f a
eac i
Februar 2012
,
ea
e
e
e ie ce a eac i
,
ea
e
e ie ce a eac i
, I ha e E i-Pe
ie
he
e
f
e - he-c
e
edica
/A
If I e
e
ie a
e ci
i
Li
/A
If I e
P ea e e
H
d
d e
a
f he b
hi c
Wha i
a
De c ibe
e
D
ha e a
e
di i
be
e c ibed f
ac i i ie
a
e
.
f dai
a agi g a
e
c
i
affec
f
i h he Peace C
i i g/
hi e e
ea
e
ce
e a ed
? If
,
e c ibed f
hi c
di i
ha
?
i g
i h he Peace C
hi c
di i
a i
ac
?
.
abi i
e
ea e de c ibe.
/A
A
he c
past two ears
di i
e i
i ed ha
A e ge
De c ibe
N/A
N/A
Add a a e g
If I e e ie ce a eac i
Li
map.peacecorps.gov/MAP/HHF/Allerg /Edit
eac i
,
ea
ha e
gh
edica a e
eac i
Da e
i
b a
f a
a e g
eac i
Februar 2012
e
e
ie
he
e
f
e - he-c
e
edica
13/14
1/18/12
map.peacecorps.gov/MAP/HHF/Allerg /Edit
/A
If I e
e ie ce a eac i
,
ea
e
e
e ie ce a eac i
, I ha e E i-Pe
ie a
e ci
i
Li
/A
If I e
P ea e e
H
d
d e
a
f he b
hi c
Wha i
a
De c ibe
e
D
ha e a
i h he Peace C
e
di i
be
affec
f
a
ac i i ie
ea
ce
e a ed
? If
,
e
.
f dai
a agi g a
e
c
i
e c ibed f
i i g/
hi e e
e
e c ibed f
hi c
di i
ha
i g
?
i h he Peace C
hi c
di i
a i
ac
?
.
abi i
ea e de c ibe.
/A
Previous
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Save
Ne t
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Closing Questions
Diagnoses
Verification
Signature
Have ou ever had an
of the following?
CARDIOVASCULAR
(Conditions of the Heart or Blood Vessels)
Heart or Major Vessel Surger
T pe of surger
/A
Date of surger
Januar 2012
When was the last time ou saw a Health Care provider in
relation to this surger :
Januar 2012
Heart Attack
Date of diagnosis:
Januar 2012
When was the last time ou saw a Health Care provider for
this condition:
Januar 2012
Congestive Heart Failure
Date of diagnosis:
Januar 2012
When was the last time ou saw a Health Care provider for
this condition:
Januar 2012
Cardiom opath
Date of diagnosis:
Januar 2012
When was the last time ou saw a Health Care provider for
this condition:
Januar 2012
Endocarditis
Date of diagnosis:
Januar 2012
map.peacecorps.go /MAP/HHF/Cardiac/Edit
1/24
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map.peacecorps.go /MAP/HHF/Cardiac/Edit
When was the last time ou saw a Health Care provider for
this condition:
Januar 2012
Pulmonar Embolism
Date of diagnosis:
Januar 2012
When was the last time ou saw a Health Care provider for
this condition:
Januar 2012
A Pacemaker
Date of insertion:
Januar 2012
When was the last time ou saw a Health Care provider for
this condition:
Januar 2012
An Implantable Defibrillator
When was the last time ou saw a Health Care provider for
this condition:
Januar 2012
Coronar Arter Disease
Date of diagnosis:
Januar 2012
When was the last time ou saw a Health Care provider for
this condition:
Januar 2012
A Heart Defect present since birth that requires speciali ed care
Describe:
N/A
When was the last time ou saw a Health Care provider for
this condition:
Januar 2012
Are ou currentl taking a bloodthining medication, other than aspirin?
Please list our blood thining medications. Separate individual
medications with a comma.
/A
I am 50 ears of age or older
I have had an electrocardiogram in the last si months.
YOU MUST CHECK ONE OF THE STATEMENTS BELOW
In the past two ears I have seen a Primar Care Ph sician or
Cardiologist for a heart or blood vessel condition
map.peacecorps.go /MAP/HHF/Cardiac/Edit
2/24
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map.peacecorps.go /MAP/HHF/Cardiac/Edit
I have not seen a doctor in the past two ears for an heart or blood
vessel condition
Date
Reason
Januar 2012
N/A
Delete
Add a visit
Please check all conditions that appl .
Diagnosis: Low Blood Pressure
Date of diagnosis:
Januar 2012
Please respond to all of the bullet points
below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
I have/had s mptoms due to this
condition
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
map.peacecorps.go /MAP/HHF/Cardiac/Edit
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map.peacecorps.go /MAP/HHF/Cardiac/Edit
I require medication either dail or as
needed for this condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
M doctor changed m medication within
the past 3 months (either stopped or started
a medication or changed the dosage of a
current medication)
List the medications that
changed and describe reason
for change:
/A
I have had tests done in the last 6
months to diagnose or monitor this
condition. This includes lab tests (such as
blood work) or radiologic tests (such as MRI,
or Echocardiograms).
I follow a special diet due to having this
condition
Describe
N/A
I am independentl monitoring m blood
pressure
This condition is stable, with normal
blood pressure over the past ear
I have been to an emergenc room or
urgent care center or have been hospitali ed
in the past 2 ears because of this condition
It is recommended b m health
professional that I see a Cardiologist for
speciali ed monitoring or follow up for this
condition
Please describe an monitoring
or follow up required:
N/A
Diagnosis: High Blood Pressure
Date of diagnosis:
Januar 2012
Please respond to all of the bullet points
below.
How does this condition affect our
map.peacecorps.go /MAP/HHF/Cardiac/Edit
4/24
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map.peacecorps.go /MAP/HHF/Cardiac/Edit
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
I have/had s mptoms due to this
condition
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as
needed for this condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
M doctor changed m medication within
the past 3 months (either stopped or started
a medication or changed the dosage of a
current medication)
List the medications that
changed and describe reason
for change:
map.peacecorps.go /MAP/HHF/Cardiac/Edit
5/24
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map.peacecorps.go /MAP/HHF/Cardiac/Edit
/A
I have had tests done in the last 6
months to diagnose or monitor this
condition. This includes lab tests (such as
blood work) or radiologic tests (such as MRI,
or Echocardiograms).
I follow a special diet due to having this
condition
Describe
N/A
I am independentl monitoring m blood
pressure
This condition is stable, with normal
blood pressure over the past ear
I have been to an emergenc room or
urgent care center or have been hospitali ed
in the past 2 ears because of this condition
It is recommended b m health
professional that I see a Cardiologist for
speciali ed monitoring or follow up for this
condition
Please describe an monitoring
or follow up required:
N/A
Diagnosis: High Cholesterol
Date of diagnosis:
Januar 2012
Please respond to all of the bullet points
below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
map.peacecorps.go /MAP/HHF/Cardiac/Edit
6/24
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map.peacecorps.go /MAP/HHF/Cardiac/Edit
/A
I have/had s mptoms due to this
condition
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as
needed for this condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
M doctor changed m medication within
the past 3 months (either stopped or started
a medication or changed the dosage of a
current medication)
List the medications that
changed and describe reason
for change:
/A
I have had tests done in the last 6
months to diagnose or monitor this
condition. This includes lab tests (such as
blood work) or radiologic tests (such as MRI,
or Echocardiograms).
I follow a special diet due to having this
condition
Describe
map.peacecorps.go /MAP/HHF/Cardiac/Edit
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map.peacecorps.go /MAP/HHF/Cardiac/Edit
N/A
This condition is stable and requires no
visits or onl a brief visit to the ph sician for
medication refills or blood work
I have been to an emergenc room or
urgent care center or have been hospitali ed
in the past 2 ears because of this condition
It is recommended b m health
professional that I see a Cardiologist for
speciali ed monitoring or follow up for this
condition
Please describe an monitoring
or follow up required:
N/A
Diagnosis: High Trigl cerides
Date of diagnosis:
Januar 2012
Please respond to all of the bullet points
below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
I have/had s mptoms due to this
condition
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
map.peacecorps.go /MAP/HHF/Cardiac/Edit
8/24
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map.peacecorps.go /MAP/HHF/Cardiac/Edit
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as
needed for this condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
M doctor changed m medication within
the past 3 months (either stopped or started
a medication or changed the dosage of a
current medication)
List the medications that
changed and describe reason
for change:
/A
I have had tests done in the last 6
months to diagnose or monitor this
condition. This includes lab tests (such as
blood work) or radiologic tests (such as MRI,
or Echocardiograms).
I follow a special diet due to having this
condition
Describe
N/A
This condition is stable and requires no
visits or onl a brief visit to the ph sician for
medication refills or blood work
I have been to an emergenc room or
urgent care center or have been hospitali ed
in the past 2 ears because of this condition
It is recommended b m health
professional that I see a Cardiologist for
speciali ed monitoring or follow up for this
condition
Please describe an monitoring
or follow up required:
N/A
Diagnosis: Peripheral Vascular Disease
map.peacecorps.go /MAP/HHF/Cardiac/Edit
9/24
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map.peacecorps.go /MAP/HHF/Cardiac/Edit
Date of diagnosis:
Januar 2012
Please respond to all of the bullet points
below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
I have/had s mptoms due to this
condition
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as
needed for this condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
M doctor changed m medication within
the past 3 months (either stopped or started
map.peacecorps.go /MAP/HHF/Cardiac/Edit
10/24
1/18/12
map.peacecorps.go /MAP/HHF/Cardiac/Edit
a medication or changed the dosage of a
current medication)
List the medications that
changed and describe reason
for change:
/A
I have had tests done in the last 6
months to diagnose or monitor this
condition. This includes lab tests (such as
blood work) or radiologic tests (such as MRI,
or Echocardiograms).
I sometimes, or all the time, require the
use of compression stockings
I had surger due to this condition
I have been told I need, or ma need,
surger in the future due to this condition
Describe:
N/A
This condition is resolved without
s mptoms for over a ear, I have no
restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
I have other blood vessel problems (such
as carotid or leg vessels)
Describe:
/A
I am currentl a smoker, or was a smoker
in the past ear
I have been to an emergenc room or
urgent care center or have been hospitali ed
in the past 2 ears because of this condition
It is recommended b m health
professional that I see a Cardiologist for
speciali ed monitoring or follow up for this
condition
Please describe an monitoring
or follow up required:
N/A
Diagnosis: Varicose Veins
map.peacecorps.go /MAP/HHF/Cardiac/Edit
11/24
1/18/12
map.peacecorps.go /MAP/HHF/Cardiac/Edit
Date of diagnosis:
Januar 2012
Please respond to all of the bullet points
below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
I have/had s mptoms due to this
condition
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as
needed for this condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
M doctor changed m medication within
the past 3 months (either stopped or started
map.peacecorps.go /MAP/HHF/Cardiac/Edit
12/24
1/18/12
map.peacecorps.go /MAP/HHF/Cardiac/Edit
a medication or changed the dosage of a
current medication)
List the medications that
changed and describe reason
for change:
/A
I have had tests done in the last 6
months to diagnose or monitor this
condition. This includes lab tests (such as
blood work) or radiologic tests (such as MRI,
or Echocardiograms).
I sometimes, or all the time, require the
use of compression stockings
I had surger due to this condition
I have been told I need, or ma need,
surger in the future due to this condition
Describe:
N/A
This condition is resolved without
s mptoms for over a ear, I have no
restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
I have other blood vessel problems (such
as carotid or leg vessels)
Describe:
/A
I am currentl a smoker, or was a smoker
in the past ear
I have been to an emergenc room or
urgent care center or have been hospitali ed
in the past 2 ears because of this condition
It is recommended b m health
professional that I see a Cardiologist for
speciali ed monitoring or follow up for this
condition
Please describe an monitoring
or follow up required:
N/A
Diagnosis: Ra naud's S ndrome
map.peacecorps.go /MAP/HHF/Cardiac/Edit
13/24
1/18/12
map.peacecorps.go /MAP/HHF/Cardiac/Edit
Date of diagnosis:
Januar 2012
Please respond to all of the bullet points
below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
I have/had s mptoms due to this
condition
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as
needed for this condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
M doctor changed m medication within
the past 3 months (either stopped or started
map.peacecorps.go /MAP/HHF/Cardiac/Edit
14/24
1/18/12
map.peacecorps.go /MAP/HHF/Cardiac/Edit
a medication or changed the dosage of a
current medication)
List the medications that
changed and describe reason
for change:
/A
I have had tests done in the last 6
months to diagnose or monitor this
condition. This includes lab tests (such as
blood work) or radiologic tests (such as MRI,
or Echocardiograms).
I had surger due to this condition
I have been told I need, or ma need,
surger in the future due to this condition
Describe:
N/A
This condition is resolved without
s mptoms for over a ear, I have no
restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
I have other blood vessel problems (such
as carotid or leg vessels)
Describe:
/A
I am currentl a smoker, or was a smoker
in the past ear
I can onl live in certain climates due to
the severit of this condition
Describe:
/A
I have been to an emergenc room or
urgent care center or have been hospitali ed
in the past 2 ears because of this condition
It is recommended b m health
professional that I see a Cardiologist for
speciali ed monitoring or follow up for this
condition
Please describe an monitoring
map.peacecorps.go /MAP/HHF/Cardiac/Edit
15/24
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map.peacecorps.go /MAP/HHF/Cardiac/Edit
or follow up required:
N/A
Diagnosis: Heart Conduction conditions (such as
palpitations or bundle branch blocks)
I was given a diagnosis for m
s mptoms)
Desecribe:
N/A
The condition causing m s mptoms is
not known and I do not have a diagnosis
Date of diagnosis:
Januar 2012
Please respond to all of the bullet points
below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
I have/had s mptoms due to this
condition
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
map.peacecorps.go /MAP/HHF/Cardiac/Edit
16/24
1/18/12
map.peacecorps.go /MAP/HHF/Cardiac/Edit
Add a s mptom
I require medication either dail or as
needed for this condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
M doctor changed m medication within
the past 3 months (either stopped or started
a medication or changed the dosage of a
current medication)
List the medications that
changed and describe reason
for change:
/A
I have had tests done in the last 6
months to diagnose or monitor this
condition. This includes lab tests (such as
blood work) or radiologic tests (such as MRI,
or Echocardiograms).
I am told I need, or ma need, a
radiofrequenc (RF) catheter ablation
procedure in the future due to this condition
I have had a radiofrequenc (RF)
catheter ablation procedure
Date of Procedure:
Januar 2012
I have a pacemaker due to this condition
Date of Insertion:
Januar 2012
I had surger due to this condition
I have been told I need, or ma need,
surger in the future due to this condition
Describe:
N/A
This condition is resolved without
s mptoms for over a ear, I have no
restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
map.peacecorps.go /MAP/HHF/Cardiac/Edit
17/24
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map.peacecorps.go /MAP/HHF/Cardiac/Edit
I have been to an emergenc room or
urgent care center or have been hospitali ed
in the past 2 ears because of this condition
It is recommended b m health
professional that I see a Cardiologist for
speciali ed monitoring or follow up for this
condition
Please describe an monitoring
or follow up required:
N/A
Diagnosis: Heart Valve Disorder
Date of diagnosis:
Januar 2012
Please respond to all of the bullet points
below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
I have/had s mptoms due to this
condition
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
map.peacecorps.go /MAP/HHF/Cardiac/Edit
18/24
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map.peacecorps.go /MAP/HHF/Cardiac/Edit
Add a s mptom
I require medication either dail or as
needed for this condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
M doctor changed m medication within
the past 3 months (either stopped or started
a medication or changed the dosage of a
current medication)
List the medications that
changed and describe reason
for change:
/A
I have had tests done in the last 6
months to diagnose or monitor this
condition. This includes lab tests (such as
blood work) or radiologic tests (such as MRI,
or Echocardiograms).
I had surger due to this condition
I have been told I need, or ma need,
surger in the future due to this condition
Describe:
N/A
This condition is resolved without
s mptoms for over a ear, I have no
restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
I have pulmonar edema
I have pulmonar h pertension
I have been to an emergenc room or
urgent care center or have been hospitali ed
in the past 2 ears because of this condition
It is recommended b m health
professional that I see a Cardiologist for
speciali ed monitoring or follow up for this
condition
Please describe an monitoring
or follow up required:
N/A
map.peacecorps.go /MAP/HHF/Cardiac/Edit
19/24
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map.peacecorps.go /MAP/HHF/Cardiac/Edit
Diagnosis: Pulmonar Valve Disorder
Date of diagnosis:
Januar 2012
Please respond to all of the bullet points
below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
I have/had s mptoms due to this
condition
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as
needed for this condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
map.peacecorps.go /MAP/HHF/Cardiac/Edit
20/24
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map.peacecorps.go /MAP/HHF/Cardiac/Edit
M doctor changed m medication within
the past 3 months (either stopped or started
a medication or changed the dosage of a
current medication)
List the medications that
changed and describe reason
for change:
/A
I have had tests done in the last 6
months to diagnose or monitor this
condition. This includes lab tests (such as
blood work) or radiologic tests (such as MRI,
or Echocardiograms).
I had surger due to this condition
I have been told I need, or ma need,
surger in the future due to this condition
Describe:
N/A
This condition is resolved without
s mptoms for over a ear, I have no
restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
I have pulmonar edema
I have pulmonar h pertension
I have been to an emergenc room or
urgent care center or have been hospitali ed
in the past 2 ears because of this condition
It is recommended b m health
professional that I see a Cardiologist for
speciali ed monitoring or follow up for this
condition
Please describe an monitoring
or follow up required:
N/A
An cardiac s mptoms (such as fainting or chest pain),
diagnosed condition, or cardiac surger not previousl
listed.
I was given a diagnosis for m
s mptoms)
Diagnosis:
N/A
Date of diagnosis:
Januar 2012
map.peacecorps.go /MAP/HHF/Cardiac/Edit
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map.peacecorps.go /MAP/HHF/Cardiac/Edit
The c
di i
ca
a dId
Da e
i g
ha e a diag
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i
f i i ia
Januar 2012
c
If
di i
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ha i g hi
De c ibe
N/A
I e ie
g i g,
a
eeded,
e f
hi c di i
P ea e e
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f he b e
i
be
.
H
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/A
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I ha e/had
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hi
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N/A
D e hi
dai ife?
Se e i :
affec
Mild
F e
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Dail
Da e
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Januar 2012
I
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De e e
Add a
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map.peacecorps.go /MAP/HHF/Cardiac/Edit
ie
edica i
ei he dai
a
22/24
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map.peacecorps.go /MAP/HHF/Cardiac/Edit
needed for this condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
M doctor changed m medication within
the past 3 months (either stopped or started
a medication or changed the dosage of a
current medication)
List the medications that
changed and describe reason
for change:
/A
I have had tests done in the last 6
months to diagnose or monitor this
condition. This includes lab tests (such as
blood work) or radiologic tests (such as MRI,
or Echocardiograms).
I had surger due to this condition
I have been told I need, or ma need,
surger in the future due to this condition
Describe:
N/A
This condition is resolved without
s mptoms for over a ear, I have no
restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
I have been to an emergenc room or
urgent care center or have been hospitali ed
in the past 2 ears because of this condition
It is recommended b m health
professional that I see a Cardiologist for
speciali ed monitoring or follow up for this
condition
Please describe an monitoring
or follow up required:
N/A
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Verification
Signature
(Conditions of the Skin)
PLEASE CHECK ONE STATEMENT BELOW
In the past two ears I have seen a Primar Care Ph sician or
Dermatologist for a skin condition. (If ou are unsure, click here for a list of
conditions).
I have not seen a doctor in the past two ears for an skin condition.
List date(s)/reason(s) for all visits in the past 2 ears
Date
Reason
Januar 2012
N/A
Delete
Add a visit
Please check all conditions that appl .
Diagnosis: C stic Acne
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
Please list an s mptoms related to this condition:
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
1/19
1/18/12
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or topical (applied to
affected area) medication either dail or as needed for
this condition
Note: Peace Corps does not support the use of Accutane
(Isotretinoin) during service
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I currentl require steroid injections OR Accutane
(Isotretinoin) to manage m acne.
I have had 2 or more episodes of C stic Acne in m
life
It is recommended b m health professional that I
see a Dermatologist for speciali ed monitoring or follow
up for this condition.
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Vulgaris Acne
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
2/19
1/18/12
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or topical (applied to
affected area) medication either dail or as needed for
this condition
Note: Peace Corps does not support the use of Accutane
(Isotretinoin) during service
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I currentl require steroid injections OR Accutane
(Isotretinoin) to manage m acne.
I have had 2 or more episodes of Vulgaris Acne in m
life
It is recommended b m health professional that I
see a Dermatologist for speciali ed monitoring or follow
up for this condition.
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
3/19
1/18/12
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
Januar 2012
Diagnosis: Unknown T pe of Acne
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or topical (applied to
affected area) medication either dail or as needed for
this condition
Note: Peace Corps does not support the use of Accutane
(Isotretinoin) during service
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I currentl require steroid injections OR Accutane
(Isotretinoin) to manage m acne.
I have had 2 or more episodes of Unknown T pe of
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
4/19
1/18/12
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
Acne in m life
It is recommended b m health professional that I
see a Dermatologist for speciali ed monitoring or follow
up for this condition.
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Alopecia (Hair Loss)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition (Unless there is a medical necessit , the Peace
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
5/19
1/18/12
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
Corps does not provide medications for hair loss for
strictl cosmetic purposes.)
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
It is recommended b m health professional that I
see a Dermatologist for speciali ed monitoring or follow
up for this condition.
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Pilonidal C st
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
6/19
1/18/12
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I had surger due to this condition
(list date(s))
N/A
I have been told I need, or ma need, surger in the
future due to this condition
(Describe):
/A
It is recommended b m health professional that I
see a Dermatologist for speciali ed monitoring or follow
up for this condition.
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Dermatitis
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
7/19
1/18/12
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
P
C
?I
,
.
/A
D
:
Januar 2012
I
/
(
)
S
: N/A
D
S
?
:
Mild
F
:
Dail
D
:
Januar 2012
I
?:
D
A
I
(
)
(
)
P
.S
.
/A
M
,
-
,
-
M
M
OR
M
L
( ):
(
)
/A
I
I
I
D
D
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
:
.
8/19
1/18/12
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
/A
Thi c di i
i e
ed
a ea , I ha e
e ic i
c di i
a di e ie
f
Da e f e
i :
ih
i ia i
he f
f
d e
e
hi
Januar 2012
Diag
i :D
S i
P ea e e
d
H
d e
dai
a
f he b
hi c
di i
i i g/
a
i g
affec
.
ac i i ie
f
a agi g a
e
hi c
di i
ha e a
a i
f
e
e c ibed f
ha
be
i h he Peace C
De c ibe
D
i
?
Wha i
hi e e
e
c
ce
ac
a
?
ea
.
e a ed
abi i
i h he Peace C
? If
e
,
hi c
e
di i
e 27
h
ea e de c ibe.
/A
Da e
f diag
i :
Januar 2012
d
I ha e/had
i
ca
S
d e
hi c
di i
(e a
e
i )
: N/A
D e hi
Se e i :
affec
dai
ife?
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
I e i e a (b
h)
ica (a
ied
affec ed a ea) edica i
ei he dai
a
eeded f
hi c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e i di id a
edica i
iha
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
9/19
1/18/12
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
.
/A
M
,
-
,
-
M
M
OR
M
L
( ):
(
)
/A
I
I
I
D
D
.
:
/A
T
,I
D
:
Januar 2012
D
:E
P
.
H
/
?
W
P
C
?
D
.
D
27
P
C
?I
,
.
/A
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
10/19
1/18/12
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
D
:
Januar 2012
I
/
(
)
S
: N/A
D
S
?
:
Mild
F
:
Dail
D
:
Januar 2012
I
?:
D
A
I
(
)
(
)
P
.S
.
/A
M
,
-
,
-
M
M
OR
M
L
( ):
(
)
/A
I
I
I
D
D
:
.
/A
T
,I
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
11/19
1/18/12
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
Da e
f e
i
:
Januar 2012
Diag
i :P
ia i
P ea e e
d
H
d e
dai
a
f he b
hi c
di i
i i g/
a
i g
affec
f
.
ac i i ie
f
a agi g a
e
e c ibed f
e
hi c
ha e a
ha
be
i h he Peace C
De c ibe
D
i
?
Wha i
hi e e
e
a i
c
a
di i
ce
?
ea
.
e a ed
ac
abi i
i h he Peace C
e
? If
,
hi c
e
di i
e 27
h
ea e de c ibe.
/A
Da e
f diag
i :
Januar 2012
d
I ha e/had
i
ca
S
d e
hi c
di i
(e a
e
i )
: N/A
D e hi
Se e i :
affec
dai
ife?
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
I e i e a (b
h)
ica (a
ied
affec ed a ea) edica i
ei he dai
a
eeded f
hi c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e i di id a
edica i
iha
c
a.
/A
M
i
e - he-c
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
d
e
i
i a d, if
i e
ea ed, e
ie
12/19
1/18/12
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
M
M
OR
M
L
( ):
(
)
/A
I
I
I
D
D
.
:
/A
T
,I
D
:
Januar 2012
D
:B
P
.
H
/
?
W
P
C
?
D
.
D
27
P
C
?I
,
.
/A
D
:
Januar 2012
L
/A
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
13/19
1/18/12
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
I have had at least one lesion located on m lips or
ears
I have a histor of same-site skin recurrences.
I have had this condition more than twice in m
lifetime
I had surgical removal of the lesion(s)
I have been told I need, or ma need, surger in the
future due to this condition
(Describe):
/A
It is recommended b m health professional that I
see a Dermatologist for speciali ed monitoring or follow
up for this condition.
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Squamous cell tumor of the skin
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
List location
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
14/19
1/18/12
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
/A
I have had at least one lesion located on m lips or
ears
I have a histor of same-site skin recurrences.
I have had this condition more than twice in m
lifetime
I had surgical removal of the lesion(s)
I have been told I need, or ma need, surger in the
future due to this condition
(Describe):
/A
It is recommended b m health professional that I
see a Dermatologist for speciali ed monitoring or follow
up for this condition.
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Moles or Nevi (These do NOT include an basal or
squamous cancers listed above)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
15/19
1/18/12
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
Januar 2012
I have had this condition more than once (complete
questions below for EACH occurrence)
I had surgical removal of the mole or nevi
After removal of the mole I was told it was abnormal
but not cancerous
It is recommended b m health professional that I
see a Dermatologist for speciali ed monitoring or follow
up for this condition.
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Fungal Infections, including Nail fungal infections
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
Location of the s mptom
/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
16/19
1/18/12
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or topical (applied to
affected area) medication either dail or as needed for
this condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
The medication I take for this condition requires
regular lab work
It is recommended b m health professional that I
see a Dermatologist for speciali ed monitoring or follow
up for this condition.
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: An skin s mptom (such as a rash or itching),
diagnosed condition, or skin surger not previousl listed.
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
17/19
1/18/12
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
/A
I was given a diagnosis for m s mptoms
Date of diagnosis:
Januar 2012
List diagnosis
N/A
I do not know the name of condition causing m
s mptoms or or I have not been given a diagnosis
(Date of initial s mptoms)
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I had surger due to this condition
I have been told I need, or ma need, surger in the
future due to this condition
(Describe):
/A
M condition has involved or currentl involves most
or all of m bod
M condition has required or currentl requires
injections OR drugs that lower m immune response
It is recommended b m health professional that I
see a Dermatologist for speciali ed monitoring or follow
up for this condition.
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
18/19
1/18/12
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Previous
map.peacecorps.gov/MAP/HHF/Dermatolog /Edit
Save
Ne t
19/19
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
Welcome ekehne Log Off
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Have ou had an of these conditions in
(Check all that appl .)
our lifetime?
ENDOCRINOLOGY
Introduction
HIPAA Signature
Opening Questions
Allergy
Cardiovascular
Dermatology
Endocrinology
Ear, Nose, Throat
Gastroenterology
Rheumatology and
Immunology
Neurology
Musculoskeletal
Infectious Disease
Hematology
Gynaecology
Respiratory
Urology and
Nephrology
Opthalmology
Mental Health
Closing Questions
Diagnoses
Verification
Signature
(Diabetes or Conditions of the Pituitar ,
Th roid, Parath roid, and Adrenal Glands)
Addison s Disease (hypo adrenal glands and/or reduced corticosteroid
levels)
Date of diagnosis:
Januar 2012
When was the last time you saw a Health Care provider for this condition:
Januar 2012
Cushing s Disease (hyper adrenal glands and/or elevated corticosteroid
levels)
Date of diagnosis:
Januar 2012
When was the last time you saw a Health Care provider for this condition:
Januar 2012
Diabetes Type 1
Date of diagnosis:
Januar 2012
When was the last time you saw a Health Care provider for this condition:
Januar 2012
Congenital Adrenal Hyperplasia
Date of diagnosis:
Januar 2012
When was the last time you saw a Health Care provider for this condition:
Januar 2012
YOU MUST CHECK ONE OF THE STATEMENTS BELOW
In the past two years I have seen a primary care physician or
endocrinologist or other specialist for a condition of the Endocrine System
(diabetes or conditions of the pituitary, thyroid, parathyroid and adrenal
glands for example). If you are unsure, click here for a list of Endocrine
conditions)
I have not seen a doctor in the past two ears for any condition of the
endocrine system
List date(s)/reason(s) for all visits in the past 2 ears
Date
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
Reason
1/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
Januar 2012
D
Date of diagnosis
A
Check all conditions or s mptoms that appl
Diagnosis: Diabetes Mellitus T pe 2 (If ou have T pe 1, this
should be checked in the lifetime conditions)
P
.
H
/
?
W
P
C
?
D
.
D
27
P
C
?I
,
.
/A
D
:
Januar 2012
I
I
)
I
(
P
(
)
I
(
)
.S
.
/A
M
3
(
L
)
:
/A
I
D
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
:
2/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
/A
I had
ge
d e
hi c
di i
I ha e bee
d I eed,
f
e d e
hi c di i
De c ibe:
i
he
a
eed,
b
d
a
2 ea
ge
i
he
/A
Ia
ab e
chec
I ha e had a He
h
g bi A1C ab e
I ha e e
a h (
d e
hi c di i
De c ibe:
f e
ga
i
he a
a i
e
e
3
ai )
/A
I ha e i
e e
f he b d
c di i
( id e , e e f e a
e)
De c ibe:
e
d e
hi
/A
I ha e had b
d e
he diag
ic e i g i
a 6
h d e
hi c di i
I ha e bee
a e e ge c
ge ca e
ce e
ha e bee h
i a i ed i he a 2 ea
beca e f hi c di i
I i ec
e ded b
hea h
fe i a ha I
ee a E d c i
gi f
ecia i ed
i i g
f
f
hi c di i .
De c ibe:
he
/A
Thi c di i
i e
ed
a ea , I ha e
e ic i
c di i
a di e ie
f
Da e f e
i :
ih
i ia i
he f
f
d e
e
hi
Januar 2012
Diagnosis: H pogl cemia
P ea e e
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
d
a
f he b
e
i
be
.
3/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I have had blood tests due to this condition in the
past 3 months
I have had this condition more than once
List:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Endocrinologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
This condition is resolved without s mptoms for over
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
4/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: : H perth roidism (overactive th roid)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication within the past 3
months (either stopped or started a medication or
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
5/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I have had blood tests or other diagnostic testing
(such as a Ultrasound) in the past ear due to this
condition
I had surger due to this condition in the past 2 ears
I have been told I need, or ma need, surger in the
future due to this condition
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Endocrinologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Grave s Disease (an autoimmune response leading
to an overactive thyroid)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
6/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication within the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I have had blood tests or other diagnostic testing
(such as a Ultrasound) in the past ear due to this
condition
I had surger due to this condition in the past 2 ears
I have been told I need, or ma need, surger in the
future due to this condition
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
7/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
It is recommended b m health professional that I
see an Endocrinologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Th roid Storm (a life- threatening event of an
overactive th roid)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
8/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication within the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I have had blood tests or other diagnostic testing
(such as a Ultrasound) in the past ear due to this
condition
I had surger due to this condition in the past 2 ears
I have been told I need, or ma need, surger in the
future due to this condition
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Endocrinologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: H poth roidism (underactive th roid)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
9/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication within the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I have had blood tests or other diagnostic testing
(such as a Ultrasound) in the past ear due to this
condition
I had surger due to this condition in the past 2 ears
I have been told I need, or ma need, surger in the
future due to this condition
Describe:
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
10/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Endocrinologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Hashimoto s or other type of Thyroiditis
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
11/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication within the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I have had blood tests or other diagnostic testing
(such as a Ultrasound) in the past ear due to this
condition
I had surger due to this condition in the past 2 ears
I have been told I need, or ma need, surger in the
future due to this condition
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Endocrinologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Underactive th roid due to a pituitar
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
d sfunction
12/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication within the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I have had blood tests or other diagnostic testing
(such as a Ultrasound) in the past ear due to this
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
13/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
condition
I had surger due to this condition in the past 2 ears
I have been told I need, or ma need, surger in the
future due to this condition
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Endocrinologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Acromegal (growth hormone secreting pituitar
tumor)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have had blood tests or other diagnostic testing
(such as an MRI) in the past ear due to this condition
I have/had s mptoms due to this condition
S mptom: N/A
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
14/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication within the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I had surger due to this condition in the past 2 ears
I have been told I need, or ma need, surger in the
future due to this condition
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Endocrinologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
15/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
Diagnosis: : Prolactin-secreting pituitar
tumor
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have had blood tests or other diagnostic testing
(such as an MRI) in the past ear due to this condition
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication within the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
16/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
/A
I had surger due to this condition in the past 2 ears
I have been told I need, or ma need, surger in the
future due to this condition
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Endocrinologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: ACTH-producing pituitar
tumor
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have had blood tests or other diagnostic testing
(such as an MRI) in the past ear due to this condition
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
17/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication within the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I had surger due to this condition in the past 2 ears
I have been told I need, or ma need, surger in the
future due to this condition
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Endocrinologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
This condition is resolved without s mptoms for over
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
18/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Non-functioning (no production of hormones)
pituitar tumor
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have had blood tests or other diagnostic testing
(such as an MRI) in the past ear due to this condition
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
19/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
/A
M doctor changed m medication within the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I had surger due to this condition in the past 2 ears
I have been told I need, or ma need, surger in the
future due to this condition
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Endocrinologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: H poparath roidism (underactive parath roid)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
20/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
/A
Date of diagnosis:
Januar 2012
I have had blood tests or other diagnostic testing
(such as an MRI) in the past ear due to this condition
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication within the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I had surger due to this condition in the past 2 ears
I have been told I need, or ma need, surger in the
future due to this condition
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
21/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
see an Endocrinologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: H perparath roidism (overactive parath roid)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have had blood tests or other diagnostic testing
(such as an MRI) in the past ear due to this condition
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
22/28
1/18/12
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication within the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I had surger due to this condition in the past 2 ears
I have been told I need, or ma need, surger in the
future due to this condition
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Endocrinologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Pheochromoc toma
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
23/28
1/18/12
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that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have had blood tests or other diagnostic testing
(such as an MRI) in the past ear due to this condition
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication within the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I had surger due to this condition in the past 2 ears
I have been told I need, or ma need, surger in the
future due to this condition
Describe:
/A
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I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Endocrinologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagno i : Go (If o ha e al ead an
e ed
e ion on
hi condi ion in ano he bod
em, do no check hi bo )
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition (include
the location of all affected joints)
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
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Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication within the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
The cause of this condition is known
List
/A
I have had more than one episode of this condition in
m lifetime
I have had laborator testing (such as uric acid
levels) or diagnostic testing (such as MRI or X-Ra ) in the
past 6 months due to this condition
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Endocrinologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: An endocrine s mptom (such as hormonal
abnormalities), diagnosed condition, or endocrine surger not
previousl listed for which ou have sought medical attention in
the past 2 ears
Please respond to all of the bullet points below.
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How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
I was given a diagnosis for m s mptoms
Diagnosis:
N/A
Date of diagnosis:
Januar 2012
I do not know the condition or I have not been given
a diagnosis
(Date of initial s mptoms)
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication within the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
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/A
I have had blood tests or other diagnostic testing
(such as a Ultrasound) in the past ear due to this
condition
I had surger due to this condition
I have been told I need, or ma need, surger in the
future due to this condition
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Endocrinologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Previous
map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit
Save
Ne t
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Welcome ekehne Log Off
Peace Corps
Home
Have ou ever had an
of the following?
EAR, NOSE and THROAT
(Conditions of the Ear, Nose and Throat)
I am hard of hearing and I use speech as m primar form of
communication
Date of diagnosis:
Januar 2012
Ear(s) affected
Left
Right
Both
Please respond to all of the bullet points below.
How does this condition affect our activities of dail
living/work?
What is our plan for managing an s mptoms while
serving with the Peace Corps?
Describe our response to all treatments prescribed for
this condition.
Do ou have an concerns related to this condition that
ma impact on our abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
The cause of the hearing loss is known
List:
/A
I have had diagnostic testing (such as a hearing test) in
due to this condition
I require the use of a hearing aid
List t pe, date of purchase, manufacturer and model
number(provide if known)
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/A
The hea ing aid ma need o be eplaced in he ne
ea
Da e of e pec ed f
e eplacemen
3
Januar 2012
I i ecommended b m heal h p ofe ional ha I ee an
Ea , No e and Th oa ph ician fo peciali ed moni o ing o
follo
p fo hi condi ion.
De c ibe
/A
I am deaf and
comm nica ion
e Ame ican Sign Lang age a m p ima
fo m of
Da e of diagno i :
Januar 2012
Plea e e pond o all of he b lle poin
Ho
doe
hi condi ion affec
belo .
o
ac i i ie of dail
li ing/ o k?
Wha i
e
o
ing
plan fo managing an
mp om
hile
i h he Peace Co p ?
De c ibe o
e pon e o all
ea men
p e c ibed fo
hi condi ion.
Do o
ha e an conce n
ma impac on o
abili
ela ed o hi condi ion ha
o e
e 27 mon h
i h he
Peace Co p ? If o, plea e de c ibe.
/A
I am deaf and
comm nica ion
e peech and e id al hea ing a m p ima
fo m of
Da e of diagno i :
Januar 2012
Plea e e pond o all of he b lle poin
Ho
doe
hi condi ion affec
o
belo .
ac i i ie of dail
li ing/ o k?
Wha i
e
ing
o
plan fo managing an
mp om
hile
i h he Peace Co p ?
De c ibe o
e pon e o all
ea men
p e c ibed fo
hi condi ion.
Do o
map.peacecorps.go /MAP/HHF/ENT/Edit
ha e an conce n
ela ed o hi condi ion ha
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ma impact on our abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
I have no difficult hearing
YOU MUST CHECK ONE OF THE STATEMENTS BELOW
In the past two ears I have seen a Primar Care Ph sician or Ear,
Nose, and Throat Specialist for an Ear, Nose, and Throat condition. (If ou
are unsure, click here for a list of conditions).
I have not seen a doctor in the past two ears for an Ear, Nose and
Throat condition.
List date(s)/reason(s) for all visits in the past 2 ears
Date
Reason
Januar 2012
N/A
Delete
Add a visit
Please check all conditions that appl .
Diagnosis: Cholesteatoma (usuall a benign tumor of the ear)
Date of diagnosis:
Januar 2012
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Ear(s) affected
Left
Right
Both
I have/had s mptoms due to this condition
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S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I have had a single incidence of a Cholesteatoma
I have had this condition more than once in m
lifetime
List Dates
/A
I had surger in the past 2 ears due to this condition
I am told I need, or ma need, surger in the future
due to this condition
Description:
/A
It is recommended b m health professional that I
see an Ear, Nose and Throat ph sician for speciali ed
monitoring or follow up for this condition
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Meniere s Disease (affects balance and hearing)
Date of diagnosis:
Januar 2012
Please respond to all of the bullet points below.
How does this condition affect our activities of
map.peacecorps.go /MAP/HHF/ENT/Edit
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dai
i i g/
?
Wha i
a
hi e e
i g
De c ibe
e c ibed f
D
a i
a agi g a
e
e
hi c
di i
ha e a
ha
f
i h he Peace C
c
a
ce
?
ea
e a ed
ac
abi i
i h he Peace C
e
.
? If
,
hi c
e
di i
e 27
h
ea e de c ibe.
/A
I ha e/had
S
d e
hi c
di i
: N/A
D e hi
Se e i :
affec
dai
ife?
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
I e i e edica i
ei he dai
a
eeded f
hi
c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e i di id a
edica i
iha
c
a.
/A
Ia c e
e e ie ci g hea i g
di i
I ha e had hi c di i
e ha
ife i e
Li Da e
d e
hi
c
ce i
/A
I had
ge
f
Ia
d I eed,
d e
hi c di i
De c i i :
map.peacecorps.go /MAP/HHF/ENT/Edit
hi c
a
di i
eed,
ge
i
he f
e
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/A
It is recommended b m health professional that I
see an Ear, Nose and Throat ph sician for speciali ed
monitoring or follow up for this condition
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Vertigo (di
iness)
Date of diagnosis:
Januar 2012
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
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Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I have had this condition more than once in m
lifetime
List Dates
/A
I had surger for this condition
I am told I need, or ma need, surger in the future
due to this condition
Description:
/A
It is recommended b m health professional that I
see an Ear, Nose and Throat ph sician for speciali ed
monitoring or follow up for this condition
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagno i :Tinni
( inging in he ea )
Date of diagnosis:
Januar 2012
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
map.peacecorps.go /MAP/HHF/ENT/Edit
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e c ibed f
D
hi c
ha e a
ha
a i
di i
c
ce
.
e a ed
ac
abi i
i h he Peace C
? If
,
hi c
e
di i
e 27
h
ea e de c ibe.
/A
I ha e/had
S
d e
hi c
di i
: N/A
D e hi
Se e i :
affec
dai
ife?
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
I e i e edica i
ei he dai
a
eeded f
hi
c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e i di id a
edica i
iha
c
a.
/A
Ia c e
e e ie ci g hea i g
di i
I ha e had hi c di i
e ha
ife i e
Li Da e
d e
hi
c
ce i
/A
I had
ge
f
hi c
Ia
d I eed,
d e
hi c di i
De c i i :
a
di i
eed,
ge
i
he f
e
/A
I i
map.peacecorps.go /MAP/HHF/ENT/Edit
ec
e ded b
hea h
fe
i
a
ha I
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see an Ear, Nose and Throat ph sician for speciali ed
monitoring or follow up for this condition
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagno i : Ea Infec ion
Date of diagnosis:
Januar 2012
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
map.peacecorps.go /MAP/HHF/ENT/Edit
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this condition. Separate individual medications with a
comma.
/A
This is a chronic condition that requires multiple visits
to a health professional each ear
Describe
/A
I had surger in the past 2 ears due to this condition
I am told I need, or ma need, surger in the future
due to this condition
Description:
/A
It is recommended b m health professional that I
see an Ear, Nose and Throat ph sician for speciali ed
monitoring or follow up for this condition
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagno i : Sin
i i
Date of diagnosis:
Januar 2012
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
map.peacecorps.go /MAP/HHF/ENT/Edit
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/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
This is a chronic condition that requires multiple visits
to a health professional each ear
Describe
/A
I had surger in the past 2 ears due to this condition
I am told I need, or ma need, surger in the future
due to this condition
Description:
/A
It is recommended b m health professional that I
see an Ear, Nose and Throat ph sician for speciali ed
monitoring or follow up for this condition
Description:
/A
map.peacecorps.go /MAP/HHF/ENT/Edit
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This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagno i : Ton illi i
Date of diagnosis:
Januar 2012
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
This is a chronic condition that requires multiple visits
map.peacecorps.go /MAP/HHF/ENT/Edit
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to a health professional each ear
Describe
/A
I had surger in the past 2 ears due to this condition
Si emap
I am told I need, or ma need, surger in the future
due to this condition
Description:
/A
Introduction
HIPAA Signature
Opening Questions
Allerg
Cardiovascular
Dermatolog
Endocrinolog
Ear, Nose, Throat
Gastroenterolog
Rheumatolog and
Immunolog
Neurolog
Musculoskeletal
Infectious Disease
Hematolog
G naecolog
Respirator
Urolog and
Nephrolog
Opthalmolog
Mental Health
Closing Questions
Diagnoses
Verification
Signature
It is recommended b m health professional that I
see an Ear, Nose and Throat ph sician for speciali ed
monitoring or follow up for this condition
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagno i : De ia ed ep
m
Date of diagnosis:
Januar 2012
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
I have/had s mptoms due to this condition
S mptom: N/A
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Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
This is a chronic condition that requires multiple visits
to a health professional each ear
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I have trouble sleeping due to this condition
I had surger for this condition
I am told I need, or ma need, surger in the future
due to this condition
Description:
/A
This is a chronic condition that requires multiple visits
to a health professional each ear
Describe
/A
It is recommended b m health professional that I
see an Ear, Nose and Throat ph sician for speciali ed
monitoring or follow up for this condition
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
map.peacecorps.go /MAP/HHF/ENT/Edit
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Diagnosis: An other s mptom or condition of the ear, nose or
throat (including surgeries) not previousl listed that has required
ou to seek medical attention in the past 2 ears
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
I was given a diagnosis for m s mptoms
(List diagnosis):
N/A
Date:
Januar 2012
I do not know the name of condition causing m
s mptoms or I have not been given a diagnosis
(Date of initial s mptoms)
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
map.peacecorps.go /MAP/HHF/ENT/Edit
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/A
This is a chronic condition that requires multiple visits
to a health professional each ear
I require special medical treatment for this condition
Describe:
/A
I had surger in the past 2 ears due to this condition
I am told I need, or ma need, surger in the future
due to this condition
Description:
/A
It is recommended b m health professional that I
see an Ear, Nose and Throat ph sician for speciali ed
monitoring or follow up for this condition
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Previous
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Ne t
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map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
Welcome ekehne Log Off
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In m lifetime I have/had:
GASTROENTEROLOGY
(Conditions of the Colon, Stomach, Pancreas or
Liver)
Cirrhosis of the Liver
Date of diagnosis:
Januar , 2012
When was the last time ou saw a Health Care provider for
this condition?
Januar , 2012
Esophageal Varices
Date of diagnosis:
Januar , 2012
When was the last time ou saw a Health Care provider for
this condition?
Januar , 2012
Ascites
Date of diagnosis:
Januar , 2012
When was the last time ou saw a Health Care provider for
this condition?
Januar , 2012
Hepatitis C
Date of diagnosis:
Januar , 2012
When was the last time ou saw a Health Care provider for
this condition?
Januar , 2012
Active Hepatitis B OR I am a Hepatitis B carrier
Date of diagnosis:
Januar , 2012
When was the last time ou saw a Health Care provider for
this condition?
Januar , 2012
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I have undergone Bariatric Surgery for weight loss
(Date of Sugery)
Januar , 2012
When was the last time you saw a Health Care provider for
this condition?
Januar , 2012
Any absorption disorder, such as Crohn s Disease or Ulcerative Colitis
Date of diagnosis:
Januar , 2012
When was the last time you saw a Health Care provider for
this condition?
Januar , 2012
I currently have a Colostomy, Ileostomy or any other surgical repair of
the colon that requires daily care and maintenance
When was the last time you saw a Health Care provider for this condition?
Januar , 2012
PLEASE CHECK AT LEAST ONE OF THE OPTIONS BELO
I am under 50 years of age
I am 50 years of age or older
PLEASE CHECK A LEA
CHECK ALL THAT APPL
ONE OF THE FOLLO
ING BO ES.
Colonoscopy (within 10 years)
My test was abnormal and required further follow up
testing
Flexible Sigmoidoscopy (within 5 years)
My test was abnormal and required further follow up
testing
Double Contrast Barium Enema (within 5 years)
My test was abnormal and required further follow up
testing
CT Colongraphy “Virtual Colonoscopy” (within 5 years)
My test was abnormal and required further follow up
testing
Stool for DNA testing (within 1 year)
My test was abnormal and required further follow up
testing
Fecal Immunochemical Test (within 1 year)
My test was abnormal and required further follow up
testing
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Feca Occ
B
d Te
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i g
e
I ha e
fa e
3 ( i hi 1 ea )
a ab
had a
a a d e
f he i ed e
i ed f
he f
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he defi ed i e
OU MUST CHECK ONE OF THE STATEMENTS BELOW
Ia
Ia
a da
ab e
e a e ac
e i
ac
e i
e a a d ha e
id
e
a dai
P ea e e
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a
f he b
hi c
di i
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i
a
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be
affec
id dai
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dif
d c
die
.
ac i i ie
f dai
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Wha i
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die a d d
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De c ibe
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?
e
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? If
ce
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abi i
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,
hi c
e 27
di i
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ha
i h he
ea e de c ibe.
/A
OU MUST CHECK ONE OF THE STATEMENTS BELOW
g
Ia
ab e
Ia
e
g
e a e g
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i
P ea e e
H
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e a
d
d e
i i g/
f he b
hi c
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a
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hi c
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i
dif
be
affec
die a d a
id
.
ac i i ie
f dai
?
f
a agi g a
i h he Peace C
De c ibe
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die
a
Wha i
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i
hich e
di i
e
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?
a
ea
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.
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ea e de c ibe.
/A
map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
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YOU MUST CHECK ONE OF THE STATEMENTS BELOW
In the past two years I have seen a Primary Care Physician or
Gastroenterologist for a Colon, Stomach, Pancreas or Liver condition (If you
are unsure, click here for a list of conditions)
I have not seen a doctor in the
Pancreas or Liver condition
Li
da e( )/ ea
( )f
a
a
i i
ea
i
Date
Reason
Januar , 2012
N/A
he
for any Colon, Stomach,
a
2 ea
Delete
Add a visit
P ea e chec a c
Diag
a ead a
e d
di i
i : He a i i (i f a
e ed
e i
chec hi b )
ha a
a i
hi c
.
f he i e ) (If
ha e
di i
i a
he b d
Please respond to all of the bullet points below.
How does this condition affect your activities of
daily living/work?
What is your plan for managing any symptoms
while serving with the Peace Corps?
Describe your response to all treatments
prescribed for this condition.
Do you have any concerns related to this condition
that may impact on your ability to serve 27 months
with the Peace Corps? If so, please describe.
/A
Hepatitis A
Date of diagnosis:
Januar , 2012
Hepatitis B
Date of diagnosis:
Januar , 2012
Hepatitis C
Date of diagnosis:
Januar , 2012
I don t know what kind of Hepatitis I had
Date of diagnosis:
Januar , 2012
The cause of this condition is known and can
prevented
Describe
map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
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/A
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar , 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) medication either dail or as
needed for this condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I have had blood tests or other diagnostic testing
(such as CT Scan or Ultrasound) in the past 6 months due
to this condition
I require regular blood tests to monitor the status of
m liver function
Date of last test
Januar , 2012
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up
Describe:
/A
This condition is resolved without s mptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar , 2012
map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
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Diagnosis: Irritable Bowel S ndrome
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
December, 2011
I have had this condition more than once
List dates:
N/A
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar , 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) medication either dail or as
needed for this condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I have had blood tests or other diagnostic testing
(such as Colonoscop ) in the past 2 ears due to this
condition
I follow a special diet due to having this condition
Describe:
map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
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N/A
I had surger due to this condition
I am told I need, or ma need, surger in the future
due to this condition
Describe:
N/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up
Describe:
/A
This condition is resolved without s mptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar , 2012
Diagnosis: Bo el Obstruction
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar , 2012
I had surger due to this condition
I am told I need, or ma need, surger in the future
due to this condition
Describe:
N/A
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up for this condition.
Describe:
map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
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/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
This condition is resolved without s mptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar , 2012
Diagnosis: Inguinal Hernia (protrusion of abdominal contents
into the lo er abdomen)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
I had surger due to this condition
(Date of Surgical Repair)
Januar , 2012
Not surgicall repaired
I am told I need, or ma need, surger in the future
due to this condition
Describe:
N/A
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
This condition is resolved without s mptoms for at
map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
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least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar , 2012
Diagnosis: Celiac Disease
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar , 2012
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar , 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) medication either dail or as
needed for this condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I have had blood tests or other diagnostic testing
(such as Colonoscop ) in the past 2 ears due to this
map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
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condition
I had surger due to this condition
I am told I need, or ma need, surger in the future
due to this condition
Describe:
N/A
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
This condition is resolved without s mptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar , 2012
Diagno i : Choleli hia i (Gallbladde
one )
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar , 2012
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
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map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
Januar , 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) medication either dail or as
needed for this condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I follow a special diet due to having this condition
Describe:
N/A
I have had blood tests or other diagnostic testing
(such as Ultrasound) in the past 2 ears due to this
condition
I had surger due to this condition
I am told I need, or ma need, surger in the future
due to this condition
Describe:
N/A
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
This condition is resolved without s mptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar , 2012
Diagnosis: Cholec stitis(inflammation of the gallbladder)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
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map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar , 2012
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar , 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) medication either dail or as
needed for this condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I follow a special diet due to having this condition
Describe:
N/A
I have had blood tests or other diagnostic testing
(such as Ultrasound) in the past 2 ears due to this
condition
I had surger due to this condition
I am told I need, or ma need, surger in the future
due to this condition
Describe:
N/A
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up for this condition.
Describe:
map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
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map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
This condition is resolved without s mptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar , 2012
Diagnosis: Cholangitis(Infection of the biliar
tract)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar , 2012
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar , 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) medication either dail or as
needed for this condition
Please list an medications ou are currentl taking for
map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
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this condition. Separate individual medications with a
comma.
/A
I follow a special diet due to having this condition
Describe:
N/A
I have had blood tests or other diagnostic testing
(such as Ultrasound) in the past 2 ears due to this
condition
I had surger due to this condition
I am told I need, or ma need, surger in the future
due to this condition
Describe:
N/A
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
This condition is resolved without s mptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar , 2012
Diagnosis: Cholec stectom (surgical removal of the
gallbladder)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
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/A
Date of Surger
Januar , 2012
Diagnosis:
N/A
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar , 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) medication either dail or as
needed for this condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I follow a special diet due to having this condition
Describe:
N/A
I have had blood tests or other diagnostic testing
(such as Ultrasound) in the past 2 ears due to this
condition
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
This condition is resolved without s mptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
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Januar , 2012
Diagno i : Panc ea i i (Inflamma ion of he panc ea )
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar , 2012
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar , 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I follow a special diet due to having this condition
Describe:
N/A
I have had blood tests or other diagnostic testing
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(
c
ch a U
di i
a
I had
d) i
ge
he
d e
a
2 ea
hi c
Ia
d I eed,
d e
hi c di i
De c ibe:
a
d e
hi
di i
eed,
ge
i
he f
e
N/A
I i ec
e ded b
ee a Ga
e e
gi f
f
f
hi c di i .
De c ibe:
hea h
fe
ecia i ed
i
i
a ha I
i g
/A
I ha e bee
a e e ge c
ce e
ha e bee h
i a i ed i
beca e f hi c di i
he
Thi c di i
i e
ed i h
6
h , I ha e
e ic i
hi c di i
a di e ie
f
Da e f e
i :
ge ca e
2 ea
a
f
ea
i ia i
he f
a
d e
Januar , 2012
Diagnosis: Colonic Pol ps and/or Pol pectom
P ea e e
H
d
a
d e
dai
f he b
hi c
i i g/
di i
a
i g
De c ibe
affec
f
.
ac i i ie
f
a agi g a
e
hi c
ha e a
ha
be
i h he Peace C
e
e c ibed f
D
i
?
Wha i
hi e e
e
a i
c
a
di i
ce
?
ea
.
e a ed
ac
abi i
i h he Peace C
e
? If
,
hi c
e
di i
e 27
h
ea e de c ibe.
/A
Da e
f diag
i :
Januar , 2012
I had a c
Da e f diag
c
i :
Januar , 2012
I had
ig
id
(Da e f e
e
c
ed a
he i e
f he c
c
a)
Januar , 2012
Da e
map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
f he
e
ec
e ded c
c
i :
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map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
N/A
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
This condition is resolved without s mptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar , 2012
Diagnosis: Gastroesophageal Reflu Disease (Heartburn)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar , 2012
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar , 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
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I require oral (b mouth) medication either dail or as
needed for this condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I follow a special diet due to having this condition
Describe:
N/A
I have had blood tests or other diagnostic testing
(such as CT Scan or Ultrasound) in the past 2 ears due
to this condition
I currentl require ongoing speciali ed management
for this condition (such as keeping the head of bed
elevated)
Describe:
/A
I had surger due to this condition
I am told I need, or ma need, surger in the future
due to this condition
Describe:
N/A
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
This condition is resolved without s mptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar , 2012
Diagnosis: Hiatal Hernia (protrusion of the stomach into the
chest cavit )
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
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while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar , 2012
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar , 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) medication either dail or as
needed for this condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I follow a special diet due to having this condition
Describe:
N/A
I have had blood tests or other diagnostic testing
(such as CT Scan or Ultrasound) in the past 2 ears due
to this condition
I currentl require ongoing speciali ed management
for this condition (such as keeping the head of bed
elevated)
Describe:
/A
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I had surger due to this condition
I am told I need, or ma need, surger in the future
due to this condition
Describe:
N/A
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
This condition is resolved without s mptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar , 2012
Diagno i : Di e ic lo i (b lging mall po che in he lining of
he colon)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition.
S mptom: Eli abeth Kehne
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
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Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) medication either dail or as
needed for this condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
The cause of this condition is known
Describe
/A
I follow a special diet due to having this condition
Describe:
N/A
I have had blood tests or other diagnostic testing
(such as Colonoscop ) in the past 2 ears due to this
condition
I am told I need, or ma need, surger in the future
due to this condition
Describe:
N/A
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
This condition is resolved without s mptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Esophagitis (inflammation or swelling of the
esophagus)
Please respond to all of the bullet points below.
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How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) medication either dail or as
needed for this condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
The cause of this condition is known
Describe
/A
I follow a special diet due to having this condition
Describe:
N/A
I have had blood tests or other diagnostic testing
(such as CT Scan or Ultrasound) in the past 2 ears due
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to this condition
I currentl require ongoing speciali ed management
for this condition (such as keeping the head of bed
elevated)
Describe:
/A
I had surger due to this condition
I am told I need, or ma need, surger in the future
due to this condition
Describe:
N/A
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
This condition is resolved without s mptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagno i : Pep ic Ulce (a m co al b eak in he
mall in e ine)
omach o
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
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I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Sitemap
Delete s mptom
Introduction
HIPAA Signature
Opening Questions
Allerg
Cardiovascular
Dermatolog
Endocrinolog
Ear, Nose, Throat
Gastroenterolog
Rheumatolog and
Immunolog
Neurolog
Musculoskeletal
Infectious Disease
Hematolog
G naecolog
Respirator
Urolog and
Nephrolog
Opthalmolog
Mental Health
Closing Questions
Diagnoses
Verification
Signature
Add a s mptom
I require oral (b mouth) medication either dail or as
needed for this condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
The cause of this condition is known
Describe
/A
I follow a special diet due to having this condition
Describe:
N/A
I have had blood tests or other diagnostic testing
(such as CT Scan or Ultrasound) in the past 2 ears due
to this condition
I currentl require ongoing speciali ed management
for this condition (such as keeping the head of bed
elevated)
Describe:
/A
I had surger due to this condition
I am told I need, or ma need, surger in the future
due to this condition
Describe:
N/A
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up for this condition.
Describe:
map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
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/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
This condition is resolved without s mptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Gastritis (inflammation of the mucosa of the
stomach)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) medication either dail or as
needed for this condition
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map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
The cause of this condition is known and can
prevented
Describe
/A
I follow a special diet due to having this condition
Describe:
N/A
I have had blood tests or other diagnostic testing
(such as CT Scan or Ultrasound) in the past 2 ears due
to this condition
I currentl require ongoing speciali ed management
for this condition (such as keeping the head of bed
elevated)
Describe:
/A
I had surger due to this condition
I am told I need, or ma need, surger in the future
due to this condition
Describe:
N/A
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
This condition is resolved without s mptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagno i : Hemo hoid
map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit
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Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) medication either dail or as
needed for this condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I follow a special diet due to having this condition
Describe:
N/A
I have had blood tests or other diagnostic testing
(such as Colonoscop ) in the past 2 ears due to this
condition
I had surger due to this condition
I am told I need, or ma need, surger in the future
due to this condition
Describe:
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N/A
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
This condition is resolved without s mptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Abdominal Pain (check onl if ou have not alread
reported this condition above)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
I was given a diagnosis for m s mptoms
Date of diagnosis:
Januar 2012
Describe:
/A
The condition causing m s mptoms is not known and
I do not have a diagnosis
Date of initial s mptoms
Januar 2012
I have/had s mptoms due to this condition.
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S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) medication either dail or as
needed for this condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I have had blood tests or other diagnostic testing
(such as MRI or Ultrasound) in the past 6 months due to
this condition
I had surger due to this condition
I am told I need, or ma need, surger in the future
due to this condition
Describe:
N/A
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
This condition is resolved without s mptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: An other Colon, Stomach, Pancreas or Liver
Condition (including surgeries) not previousl listed for which ou
have sought medical attention in the past 2 ears
Please respond to all of the bullet points below.
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How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
I was given a diagnosis for m s mptoms
Date of diagnosis:
Januar 2012
Describe:
/A
I do not know the name of condition causing m
s mptoms or or I have not been given a diagnosis
Date of initial s mptoms
Januar 2012
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) medication either dail or as
needed for this condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I follow a special diet due to having this condition
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Describe:
N/A
I have had blood tests or another diagnostic test
(such as CT Scan) in the past 6 months due to this
condition provide results
I had surger due to this condition
I am told I need, or ma need, surger in the future
due to this condition
Describe:
N/A
It is recommended b m health professional that I
see a Gastroenterologist for speciali ed monitoring or
follow up for this condition.
Describe:
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
This condition is resolved without s mptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar 2012
Previous
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Ne t
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Welcome ekehne Log Off
Peace Corps
Home
RHEUMATOLOGY AND IMMUNOLOGY
(Diseases caused b an overactive immune
s stem and chronic inflammation)
In m
lifetime I have been diagnosed with:
Ank losing Spond litis
Date of diagnosis:
Januar 2012
When was the last time ou saw a health care provider for this
condition?
Januar 2012
S stemic Lupus Er thematosus
Date of diagnosis:
Januar 2012
When was the last time ou saw a health care provider for this
condition?
Januar 2012
Pol m ositis; Dermatom ositis
Date of diagnosis:
Januar 2012
When was the last time ou saw a health care provider for this
condition?
Januar 2012
Scleroderma
Date of diagnosis:
Januar 2012
When was the last time ou saw a health care provider for this
condition?
Januar 2012
Psoriatic Arthritis
Date of diagnosis:
Januar 2012
When was the last time ou saw a health care provider for this
condition?
Januar 2012
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Fibrom algia
Please respond to all of the bullet points below.
How does this condition affect our activities of dail
living/work?
What is our plan for managing an s mptoms while
serving with the Peace Corps?
Describe our response to all treatments prescribed for
this condition.
Do ou have an concerns related to this condition that
ma impact on our abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
When was the last time ou were seen b a health care
professional for this condition?
Januar 2012
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition.
Please list an medications ou are currentl taking for this
condition. Separate individual medications with a comma.
/A
M doctor changed m medication in the past three
months (either stopped or started a medication or changed
the dosage of a current medication).
List reasons for change:
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/A
I ha e
ear d e
i
ed
hi c
ch
e ha
ce in the past
di i
I ha e had a b
d e
past ear d e
hi c di i
I ha e e ic i
e a
e, I ca '
,
Li :
he diag
ic e
in the
.
ac i i
d e
hi c
di i
(f
a ).
/A
I ha e
Li :
g i g
edica
be
d e
hi c
di i
.
/A
Ic e
c di i
Li :
i i e he f
f he a
(e e ci e, a age, h ica
i he ea
he a ).
e
f
/A
I ha
ha e
c di i
Thi
over a
c di i
Da e f
e bee
a
bee h
ia
.
c di i
ha
ear, I ha e
a di e i
e
i :
e e ge c
ge ca e ce e
i ed i the past two ears d e
hi
bee
e
e
e
ed i h
ic i
i ia i
f he f
.
for
hi
d e
Januar 2012
Ch
ic Fa ig e S
P ea e e
H
d
d
d e
i i g/
e
a
f he b
hi c
di i
a
i g
hi c
f
di i
e
.
ac i i ie
f dai
a agi g a
Peace C
e
hi e
?
a
ea
e
e c ibed f
.
ha e a
a i
map.peaceco p .go /MAP/HHF/Imm /Edi
be
affec
i h he Peace C
De c ibe
D
i
?
Wha i
e
e
c
ac
? If
,
ce
e a ed
abi i
e
e 27
hi c
di i
h
ha
i h he
ea e de c ibe.
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/A
Da e
f diag
i :
Januar 2012
Whe
fe
i
a
he a
i e
a f
hi c di i
e e ee
?
b a hea h ca e
Januar 2012
I ha e/had
S
d e
hi c
di i
.
: N/A
D e hi
Se e i :
affec
dai
ife?
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
I e i e edica i
ei he dail or as needed f
c di i .
P ea e i a
edica i
a e c e
a i gf
c di i . Se a a e i di id a
edica i
ihac
hi
hi
a.
/A
M d c
cha ged
edica i
in the past three
months (ei he
ed
a ed a edica i
cha ged
he d age f a c e
edica i ).
Li
ea
f cha ge:
/A
I ha e i ed
ch
e ha
ce in the past
ear d e
hi c di i .
I ha e had a b
d e
he diag
ic e
in the
past ear d e
hi c di i .
I ha e e ic i
ac i i d e
hi c di i
(f
e a
e, I ca '
,
a ).
Li :
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/A
I ha e
Li :
g i g
edica
be
d e
hi c
di i
/A
Ic e
c di i
Li :
i i e he f
f he a
(e e ci e, a age, h ica
i he ea
he a ).
e
f
/A
I ha
ha e
c di i
Thi
over a
c di i
Da e f
e bee
a
bee h
ia
.
c di i
ha
ear, I ha e
a di e i
e
i :
e e ge c
ge ca e ce e
i ed i the past two ears d e
hi
bee
e
e
e
ed i h
ic i
i ia i
f he f
.
for
hi
d e
Januar 2012
Rhe
a
id A h i i
P ea e e
H
d
d e
i i g/
a
f he b
hi c
di i
a
i g
D
I
d ci
HIPAA Sig a
e
O e i gQ e i
A e g
Ca di a c a
De a
g
E d ci
g
Ea , N e, Th a
Ga
e e
g
Rhe
a
g a d
I
g
Ne
g
M c
ee a
I fec i
Di ea e
He a
g
map.peaceco p .go /MAP/HHF/Imm /Edi
f
.
ac i i ie
f dai
a agi g a
e
di i
e
c
ac
Peace C
hi e
?
a
ea
e
e c ibed f
.
ha e a
a i
Sitemap
be
affec
i h he Peace C
De c ibe
hi c
i
?
Wha i
e
e
? If
ce
e a ed
abi i
e
,
hi c
e 27
di i
h
ha
i h he
ea e de c ibe.
/A
Da e
f diag
i :
Januar 2012
Whe
fe
i
a
he a
i e
a f
hi c di i
e e ee
?
b a hea h ca e
Januar 2012
I ha e/had
d e
hi c
di i
.
5/16
1/18/12
map.peaceco p .go /MAP/HHF/Imm /Edi
G aec
g
Re i a
U
g a d
Ne h
g
O ha
g
Me a Hea h
C
i gQ e i
Diag
e
Ve ifica i
Sig a
e
S
: N/A
D e hi
Se e i :
affec
dai
ife?
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
I e i e edica i
ei he dail or as needed f
c di i .
P ea e i a
edica i
a e c e
a i gf
c di i . Se a a e i di id a
edica i
ihac
hi
hi
a.
/A
M d c
cha ged
edica i
in the past three
months (ei he
ed
a ed a edica i
cha ged
he d age f a c e
edica i ).
Li
ea
f cha ge:
/A
I ha e i ed
ch
e ha
ce in the past
ear d e
hi c di i .
I ha e had a b
d e
he diag
ic e
in the
past ear d e
hi c di i .
I ha e e ic i
ac i i d e
hi c di i
(f
e a
e, I ca '
,
a ).
Li :
/A
I ha e
Li :
g i g
edica
be
d e
hi c
di i
.
/A
Ic e
c di i
Li :
map.peaceco p .go /MAP/HHF/Imm /Edi
i i e he f
f he a
(e e ci e, a age, h ica
i he ea
he a ).
e
f
6/16
1/18/12
map.peaceco p .go /MAP/HHF/Imm /Edi
/A
I ha e bee
ha e bee h
c di i .
a e e ge c
ge ca e ce e
i a i ed i the past two ears d e
hi
I i eed
hi c di i
f
De c ibe:
ee a
he e
ecia i
ha e
h ee ea .
ecific f
f
/A
Thi c di i
ha bee
over a ear, I ha e
e
c di i
a di e ie
Da e f e
i :
e
ed i h
ic i
i ia i
f he f
.
for
hi
d e
Januar 2012
J
e i e Rhe
a
P ea e e
id A h i i
d
H
d e
i i g/
a
f he b
hi c
di i
a
i g
hi c
be
affec
f
.
ac i i ie
f dai
a agi g a
i h he Peace C
De c ibe
e
di i
D
i
?
Wha i
e
e
c
ac
Peace C
?
a
ea
e
e c ibed f
.
ha e a
a i
e
hi e
? If
ce
e a ed
abi i
e
,
hi c
e 27
di i
h
ha
i h he
ea e de c ibe.
/A
Da e
f diag
i :
Januar 2012
Whe
fe
i
a
he a
i e
a f
hi c di i
e e ee
?
b a hea h ca e
Januar 2012
I ha e/had
S
d e
hi c
di i
.
: N/A
D e hi
Se e i :
affec
dai
ife?
Mild
F e
map.peaceco p .go /MAP/HHF/Imm /Edi
e c :
7/16
1/18/12
map.peaceco p .go /MAP/HHF/Imm /Edi
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
I e i e edica i
ei he dail or as needed f
c di i .
P ea e i a
edica i
a e c e
a i gf
c di i . Se a a e i di id a
edica i
ihac
hi
hi
a.
/A
M d c
cha ged
edica i
in the past three
months (ei he
ed
a ed a edica i
cha ged
he d age f a c e
edica i ).
Li
ea
f cha ge:
/A
I ha e i ed
ch
e ha
ce in the past
ear d e
hi c di i .
I ha e had a b
d e
he diag
ic e
in the
past ear d e
hi c di i .
I ha e e ic i
ac i i d e
hi c di i
(f
e a
e, I ca '
,
a ).
Li :
/A
I ha e
Li :
g i g
edica
be
d e
hi c
di i
.
/A
Ic e
c di i
Li :
i i e he f
f he a
(e e ci e, a age, h ica
i he ea
he a ).
e
f
/A
I ha e bee
ha e bee h
c di i .
map.peaceco p .go /MAP/HHF/Imm /Edi
a e e ge c
ge ca e ce e
i a i ed i the past two ears d e
hi
8/16
1/18/12
map.peaceco p .go /MAP/HHF/Imm /Edi
I will need to see a specialist or have specific follow up for
this condition for the next three years.
Describe:
/A
This condition has been resolved without symptoms for
over a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up.
Date of resolution:
Januar 2012
In the past two ears I have seen a Primary Care Physician,
Immunologist or Rheumatologist for any condition caused by chronic
inflammation from an overactive immune system or ailments of the joints
such as arthritis. (If you re unsure, click here for a list of conditions).
I have not seen a doctor in the past two ears for any condition caused
by chronic inflammation from an overactive immune system, or ailment of
the joints such as arthritis.
Date
Reason
Januar 2012
N/A
Delete
Add a visit
Diagnosis: Reactive Arthritis(Reiter's Syndrome)
Please respond to all of the bullet points
below.
How does this condition affect your
activities of daily living/work?
What is your plan for managing any
symptoms while serving with the
Peace Corps?
Describe your response to all
treatments prescribed for this
condition.
Do you have any concerns related to
this condition that may impact on your
ability to serve 27 months with the
Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have had more than one episode of this
condition in my lifetime.
List frequency:
map.peaceco p .go /MAP/HHF/Imm /Edi
9/16
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map.peaceco p .go /MAP/HHF/Imm /Edi
/A
c
I ha e/had
di i .
S
d e
hi
:
N/A
D e
hi
affec
dai ife?
Se e i :
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
I e i e a (b
h)
i ha ed
edica i
ei he dail or as needed f
hi
c di i .
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e i di id a
edica i
ihac
a.
/A
M d c
cha ged
edica i
in the
past three months (ei he
ed
a ed a edica i
cha ged he d age
fac e
edica i ).
Li :
/A
I ha e had a b
d e
he
diag
ic e
in the past ear d e
hi
c di i .
I ha e e ic i
ac i i d e
hi c di i
(f e a
e, I ca '
,
a ).
Li :
/A
map.peaceco p .go /MAP/HHF/Imm /Edi
10/16
1/18/12
map.peaceco p .go /MAP/HHF/Imm /Edi
I
L
.
:
/A
I
L
,
:
(
).
,
/A
I
the past two ears
I
D
.
.
:
/A
T
for over a ear, I
D
.
:
Januar 2012
D
:S
P
' S
.
H
/
?
W
P
C
?
D
.
D
27
P
map.peaceco p .go /MAP/HHF/Imm /Edi
C
?I
,
.
11/16
1/18/12
map.peaceco p .go /MAP/HHF/Imm /Edi
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this
condition.
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or inhaled
medication either dail or as needed for this
condition.
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
I have other conditions due to overactive
immune s stem (such as lupus or rheumatoid
arthritis).
Describe:
/A
I have multiple organ involvement from
this condition.
Describe:
/A
I have had a blood test or other
diagnostic tests in the past ear due to this
condition.
map.peaceco p .go /MAP/HHF/Imm /Edi
12/16
1/18/12
map.peaceco p .go /MAP/HHF/Imm /Edi
I ha e e ic i
hi c di i
(f e a
a ).
Li :
ac i i
e, I ca '
d e
,
/A
I ha e
hi c di i
Li :
g i g
.
edica
be
d e
/A
Ic e
i i e he f
he ea e
f
c di i
a age, h ica he a ).
Li :
f he a
(e e ci e,
i
/A
I ha e bee
a e
ge ca e ce e
ha
i the past two ears d
I i eed
ee a
ecific f
f
hi
e
h ee ea .
De c ibe:
e ge c
e bee h
i a i ed
e
hi c di i .
ecia i
ha e
c di i
f
he
/A
Thi c
di i
i e
ed i h
for over two ears, I ha e
e ic i
i ia i
d e
hi
c di i
a di e ie
f he f
Da e f e
i :
.
Januar 2012
Diag
s mptom,
i ed f
past two
i :A
rheumatoid or immunologic
diagnosed condition or surger
e i
hich
ha e
gh
edica a e i
i the
ears.
P ea e e
be
.
H
d
d e
ac i i ie
Wha i
a
f he b
hi c
f dai
di i
a
f
i
affec
i i g/
hi e e
map.peaceco p .go /MAP/HHF/Imm /Edi
e
?
a agi g a
i g
i h he
13/16
1/18/12
map.peaceco p .go /MAP/HHF/Imm /Edi
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
Actual diagnosis
I was given a diagnosis for
m s mptoms.
Date:
Januar 2012
List diagnosis:
/A
I don't know the name of
the condition causing m
s mptoms or I have not been
given a diagnosis.
Date of initial s mptoms:
Januar 2012
I have/had s mptoms due to this
condition.
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as
needed for this condition.
map.peaceco p .go /MAP/HHF/Imm /Edi
14/16
1/18/12
map.peaceco p .go /MAP/HHF/Imm /Edi
P ea e i
a i gf
edica i
a
edica i
a e c e
hi c di i . Se a a e i di id a
ihac
a.
/A
I ha e
i
e
a h i i ).
De c ibe:
he c di i
e ( ch a
d e
e ac i e
he
a id
/A
I ha e
hi c di i
De c ibe:
i e
ga
i
e e
f
.
/A
I ha e a had b
d e
he
diag
ic e
in the past ear d e
hi
c di i .
I ha e e ic i
ac i i d e
hi c di i
(f e a
e, I ca '
,
a ).
Li :
/A
I ha e
hi c di i
Li :
g i g
.
edica
be
d e
/A
Ic e
e
ea f
c di i
h ica he a ).
Li :
he f
f he a
(e e ci e, a age,
/A
I ha e bee
a e
ge ca e ce e
ha
i the past two ears d
I i eed
ee a
ecific f
f
hi
map.peaceco p .go /MAP/HHF/Imm /Edi
e ge c
e bee h
i a i ed
e
hi c di i .
ecia i
ha e
c di i
f
he
15/16
1/18/12
map.peaceco p .go /MAP/HHF/Imm /Edi
e
h ee ea
De c ibe:
.
/A
Thi c
di i
i e
ed i h
for over two ears, I ha e
e ic i
i ia i
d e
hi
c di i
a di e ie
f he f
Da e f e
i :
.
Januar 2012
Previous
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Save
Ne t
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Welcome ekehne Log Off
Peace Corps
Home
NEUROLOGY
Sitemap
Introduction
HIPAA Signature
Opening Questions
Allerg
Cardiovascular
Dermatolog
Endocrinolog
Ear, Nose, Throat
Gastroenterolog
Rheumatolog and
Immunolog
Neurolog
Musculoskeletal
Infectious Disease
Hematolog
G naecolog
Respirator
Urolog and
Nephrolog
Opthalmolog
Mental Health
Closing Questions
Diagnoses
Verification
Signature
(Conditions of the Brain or Nervous S stem)
In m
lifetime I have had:
Am otrophic Lateral Sclerosis (ALS)
Date of diagnosis:
Januar 2012
Month/Year last seen ph sician for this condition
Januar 2012
Multiple Sclerosis (MS)
Date of diagnosis:
Januar 2012
Month/Year last seen ph sician for this condition
Januar 2012
Parkinson's Disease
Date of diagnosis:
Januar 2012
Month/Year last seen ph sician for this condition
Januar 2012
M asthenia Gravis
Date of diagnosis:
Januar 2012
Month/Year last seen ph sician for this condition
Januar 2012
Cerebral Pals (CP)
Date of diagnosis:
Januar 2012
Month/Year last seen ph sician for this condition
Januar 2012
Muscular D stroph (MD)
Date of diagnosis:
Januar 2012
Month/Year last seen ph sician for this condition
Januar 2012
Cerebral Vascular Accident (CVA)
Date of diagnosis:
Januar 2012
Month/Year last seen ph sician for this condition
Januar 2012
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Surger and placement of a Ventricular Shunt
Date of Surger
1/13
1/18/12
map.peaceco p .go /MAP/HHF/Ne o/Edi
Da e
fS
ge
Januar 2012
M
h/Yea
a
ee
h
T
e e' S d
Da e f diag
i :
e
icia
f
hi c
di i
icia
f
hi c
di i
Januar 2012
Januar 2012
M
h/Yea
a
ee
h
Januar 2012
S ee A ea ha
PAP achi e
Da e f diag
i :
e
ie
a
e
ie i
hi c
di i
he
e
h ee ea
a C-
Januar 2012
M
h/Yea
a
ee
h
icia
f
Januar 2012
Sei
e di
de (
he
ha
a ei
e a a bab ca
ed b high fe e )
Li
/A
Da e
f diag
i :
Januar 2012
M
h/Yea
a
ee
h
icia
f
hi c
di i
Januar 2012
A
M
a h (a
e
c a di
de )
e i
i ed
Li
/A
Da e
f diag
i :
Januar 2012
M
h/Yea
a
ee
h
icia
f
hi c
di i
Januar 2012
YOU MUST CHECK ONE OF THE STATEMENTS BELOW
I the past two ears I ha e ee a P i a Ca e Ph
g (B ai
Ne
S
e )
ecia i f a c di
Ne
S
e .(If
'e
e, c ic he e f a i
f
I ha e
ee a d c
i he past two ears f a
B ai
Ne
S
e .
Ne
Da e
Rea
Januar , 2012
N/A
icia
i
f he B ai
c di i
)
c di i
f he
De e e
Add a i i
Diag
i : Be ' Pa
P ea e e
be
.
map.peaceco p .go /MAP/HHF/Ne o/Edi
d
a
f he b
e
i
2/13
1/18/12
map.peaceco p .go /MAP/HHF/Ne o/Edi
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar , 2012
I have/had s mptoms due to this
condition.
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar , 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) medication
either dail or as needed for this condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
I have had blood tests due to this
condition in the past three months
It is recommended b m health
professional that I see a Neurologist for
speciali ed monitoring or follow up for this
map.peaceco p .go /MAP/HHF/Ne o/Edi
3/13
1/18/12
map.peaceco p .go /MAP/HHF/Ne o/Edi
condition
Describe
/A
This condition is resolved without
s mptoms fo a lea
h ee mon h , I have
no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution
Januar 2012
Diagnosis: Migraine or other severe Headaches
Please respond to all of the bullet points
below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this
condition.
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
map.peaceco p .go /MAP/HHF/Ne o/Edi
4/13
1/18/12
map.peaceco p .go /MAP/HHF/Ne o/Edi
I
?:
D
A
I
(
)
dail or as needed
P
.S
.
/A
O
(
(
))
O
.
M
past three months (
in the
)
L
/A
I
si months
(
MRI) in the past
I
D
/A
M
onl
,
.
D
/A
I
I
map.peaceco p .go /MAP/HHF/Ne o/Edi
N
5/13
1/18/12
map.peaceco p .go /MAP/HHF/Ne o/Edi
De c ibe
/A
Thi c
di i
i e
ed i h
for over a ear, I ha e
e ic i
i ia i
d e
hi
c di i
a di e ie
f he f
Da e f e
i
Januar 2012
Diag
i : S ee A ea
(If
ha e a ead a
e ed
e i
hi
c di i
i a
he b d
e , do not chec hi b
P ea e e
be
.
d
H
d e
ac i i ie
a
f he b
hi c
di i
f dai
Wha i
f
hi e e
c
e
e
di i
D
i g
e
i h he
a
e c ibed f
hi
.
ha e a
hi c
?
a agi g a
?
De c ibe
ea
i
affec
i i g/
a
Peace C
e
)
di i
abi i
e
Peace C
c
ce
ha
e 27
? If
e a ed
a i
h
,
ac
i h he
ea e de c ibe.
/A
Da e
f diag
i :
Januar 2012
c
I ha e/had
di i .
S
d e
hi
:
N/A
D e hi
dai ife?
Se e i :
affec
Mild
F e
e c :
Dail
Da e
map.peaceco p .go /MAP/HHF/Ne o/Edi
f a
cc
e ce:
6/13
1/18/12
map.peaceco p .go /MAP/HHF/Ne o/Edi
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require the use of a C-PAP machine
This condition sometimes impacts on m
abilit to perform m activities of dail living
I have undergone sleep studies in the
past ear
It is recommended b m health
professional that I see a Neurologist for
speciali ed monitoring or follow up for this
condition
Describe
/A
This condition is resolved without
s mptoms for over a ear, I have no
restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution
Januar 2012
Diagnosis: Narcoleps
Please respond to all of the bullet points
below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
Date of diagnosis:
map.peaceco p .go /MAP/HHF/Ne o/Edi
7/13
1/18/12
map.peaceco p .go /MAP/HHF/Ne o/Edi
Januar 2012
c
I ha e/had
di i .
S
d e
hi
:
N/A
D e
hi
affec
dai ife?
Se e i :
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
I e i e a (b
h) edica i
ei he dail or as needed f
hi c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e i di id a
edica i
ihac
a.
/A
I ha e diffic ie d e
ha
e i e affec a
De c ibe
hi c
ec
f
di i
ife
/A
I ha e
de g e ee
die i the
past ear
M
a e i
a d a aged
onl
ih
e - he-c
e
edica i
he ech i e
ch a e a a i ,
ee .
De c ibe
/A
I i ec
fe i a
ecia i ed
c di i
De c ibe
map.peaceco p .go /MAP/HHF/Ne o/Edi
e ded b
hea h
ha I ee a Ne
gi f
i i g
f
f
hi
8/13
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/A
This condition is resolved without
s mptoms for over a ear, I have no
restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution
Januar 2012
Diagnosis: Insomnia
Please respond to all of the bullet points
below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this
condition.
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
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De e e
Add a
I e i e a (b
h) edica i
ei he dail or as needed f
hi c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e i di id a
edica i
ihac
a.
/A
O e f he edica i
i ed ab
i c de
ee i g i
ch a A bie
L e a
I ha e diffic ie d e
ha
e i e affec a
De c ibe
hi c
ec
f
e
di i
ife
/A
I ha e
past ear
de g
e
ee
die i the
M
a e i
a d a aged
onl
ih
e - he-c
e
edica i
he ech i e
ch a e a a i ,
ee .
De c ibe
/A
I i ec
fe i a
ecia i ed
c di i
De c ibe
e ded b
hea h
ha I ee a Ne
gi f
i i g
f
f
hi
/A
Thi c
di i
i e
ed i h
for over a ear, I ha e
e ic i
i ia i
d e
hi
c di i
a di e ie
f he f
Da e f e
i
Januar 2012
Diag
i :A
f he B ai
Ne
map.peaceco p .go /MAP/HHF/Ne o/Edi
he
S
e
, c di i
ge
(not previousl listed)
10/13
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for which ou have sought medical attention in the past
two ears.
Please respond to all of the bullet points
below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
Date
Januar 2012
I was given a diagnosis for m s mptoms
Date
Januar 2012
List diagnosis
/A
I don't know the name of condition
causing m s mptoms or I have not been
given a diagnosis
Date of initial s mptoms
Januar 2012
I have/had s mptoms due to this
condition.
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
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Delete s mptom
Add a s mptom
I require oral (b mouth) medication
either dail or as needed for this condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
M doctor changed m medication in the
past three months (either stopped or
started a medication or changed the dosage
of a current medication)
List reasons
/A
I have had blood tests or ohter
diagnostic testing (such as MRI) in the past
si months due to this condition
I had surger due to this condition
I am told I need, or ma need, surger in
the future due to this condition
Describe
/A
I have been to an emergenc room or
urgent care center or have been hospitali ed
in the past t o ears because of this
condition.
It is recommended b m health
professional that I see a Neurologist for
speciali ed monitoring or follow up for this
condition
Describe
/A
This condition is resolved without
s mptoms for o er a ear, I have no
restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution
Januar 2012
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Previous
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Save
Ne t
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c lo kele al/Edi
Welcome ekehne Log Off
Peace Corps
Home
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In od c ion
HIPAA Signa
e
Opening Q e ion
Alle g
Ca dio a c la
De ma olog
Endoc inolog
Ea , No e, Th oa
Ga oen e olog
Rhe ma olog and
Imm nolog
Ne olog
M c lo kele al
Infec io
Di ea e
Hema olog
G naecolog
Re pi a o
U olog and
Neph olog
Op halmolog
Men al Heal h
Clo ing Q e ion
Diagno e
Ve ifica ion
Signa
e
MUSCULOSKELETAL
(Conditions of the Muscle, Bone, Tendon or
Ligament)
I ha e had o hopedic
ge in m life ime and ha d a e (pin , od ,
join eplacemen fo e ample) a lef in place.
Plea e li
pe of
ge o
ge ie a
ell a he da e of
ge ,
ea on fo
ge , and ha ha d a e a lef in place.
/A
In he pa
o ea I ha e een a P ima Ca e Ph ician, O hopedic
S geon o o he Heal h Ca e P o ide (Ph ical The api o Chi op ac o
fo e ample) fo a condi ion of he M cle, Bone, Tendon o Ligamen .(If o
a e n
e, click he e fo a li of condi ion )
I ha e no een a doc o in he past two ears fo an condi ion of he
M cle, Bone, Tendon o Ligamen .
Da e
Rea on
Januar 2012
N/A
Dele e
Add a i i
Please check all conditions that appl .
Diagno i : An inj
,
ge o pain (on a eg la o in e mi en
ba i ), o fo an ea on o gh medical ca e fo Back or Spine
Plea e e pond o all of he b lle poin
Ho
doe
hi condi ion affec
o
belo .
ac i i ie of
dail li ing/ o k?
Wha i
o
hile e
ing
plan fo managing an
i h he Peace Co p ?
De c ibe o
e pon e o all
p e c ibed fo
hi condi ion.
Do o
mp om
ha e an conce n
ha ma impac on o
ea men
ela ed o hi condi ion
abili
o e
e 27 mon h
i h he Peace Co p ? If o, plea e de c ibe.
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/A
Date of diagnosis:
Januar 2012
I have had more than one episode of this condition in
my lifetime
(which diagnosis (es) and dates)
/A
I have/had symptoms due to this condition
Symptom: N/A
Does this symptom affect your daily life?
Severity:
Mild
Frequency:
Dail
Date of last occurence:
Januar 2012
Is this an ongoing symptom?:
Delete symptom
Add a symptom
I currently require ongoing medical treatment for this
condition
Describe:
/A
I require a brace or other medical equipment due to
this condition
Describe:
/A
I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery for this condition
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D
:
Januar 2012
I
I
D
:
/A
I
D
:
Januar 2012
I
(
MRI
X-R
)
I
2
T
,I
D
:
Januar 2012
D
)
Nec
:A
,
(
,
P
.
H
/
?
W
P
C
?
D
.
D
27
P
C
?I
,
.
/A
D
:
Januar 2012
I
(
map.peaceco p .go /MAP/HHF/M
c lo kele al/Edi
(
)
)
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/A
I have/had symptoms due to this condition
Symptom: N/A
Does this symptom affect your daily life?
Severity:
Mild
Frequency:
Dail
Date of last occurence:
Januar 2012
Is this an ongoing symptom?:
Delete symptom
Add a symptom
I currently require ongoing medical treatment for this
condition
Describe:
/A
I require a brace or other medical equipment due to
this condition
Describe:
/A
I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery for this condition
Date of surgery:
Januar 2012
I have been told I may need surgery in the future for
this condition
Describe:
/A
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I
D
:
Januar 2012
I
(
MRI
X-R
)
I
2
T
,I
D
:
Januar 2012
D
)
Sk ll
:A
,
(
,
P
.
H
/
?
W
P
C
?
D
.
D
27
P
C
?I
,
.
/A
D
:
Januar 2012
I
(
(
)
)
/A
I
/
S
D
S
: N/A
?
:
Mild
F
map.peaceco p .go /MAP/HHF/M
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:
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Dail
Date of last occurence:
Januar 2012
Is this an ongoing symptom?:
Delete symptom
Add a symptom
I currently require ongoing medical treatment for this
condition
Describe:
/A
I require a brace or other medical equipment due to
this condition
Describe:
/A
I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery for this condition
Date of surgery:
Januar 2012
I have been told I may need surgery in the future for
this condition
Describe:
/A
I had physical therapy in the past six months for this
condition
Date of last session:
Januar 2012
I have had diagnostic testing (such as MRI or X-Ray)
due to this condition provide results
I have been to an emergency room or urgent care
center or have been hospitalized in the past 2 years
because of this condition
This condition is resolved without symptoms or pain
for six months or more, I have no restrictions or
limitations due to this condition and it requires no further
follow up
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Date of resolution:
Januar 2012
Diagnosis: An injur , surger or pain (on a regular or intermittent
basis)in relation to, or for an reason sought medical care for the
K ee
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
Location:
Left
Right
Both
I have had more than one episode of this condition in
m lifetime
(which diagnosis (es) and dates)
/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
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I require medication either daily or as needed for this
condition (Include pain medications)
Please list any medications you are currently taking for
this condition. Separate individual medications with a
comma.
/A
I currently require ongoing medical treatment for this
condition
Describe:
/A
I require a brace or other medical equipment due to
this condition
Describe:
/A
I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery for this condition
Date of surgery:
Januar 2012
I have been told I may need surgery in the future for
this condition
Describe:
/A
I had physical therapy in the past six months for this
condition
Date of last session:
Januar 2012
I have had diagnostic testing (such as MRI or X-Ray)
due to this condition provide results
I have been to an emergency room or urgent care
center or have been hospitalized in the past 2 years
because of this condition
This condition is resolved without symptoms or pain
for six months or more, I have no restrictions or
limitations due to this condition and it requires no further
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follow up
Date of resolution:
Januar 2012
Diagnosis: An injur , surger or pain (on a regular or intermittent
basis) in relation to, or for an reason sought medical care for the
Sho lder
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
Location:
Left
Right
Both
I have had more than one episode of this condition in
m lifetime
(which diagnosis (es) and dates)
/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
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Add a symptom
I require medication either daily or as needed for this
condition (Include pain medications)
Please list any medications you are currently taking for
this condition. Separate individual medications with a
comma.
/A
I currently require ongoing medical treatment for this
condition
Describe:
/A
I require a brace or other medical equipment due to
this condition
Describe:
/A
I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery for this condition
Date of surgery:
Januar 2012
I have been told I may need surgery in the future for
this condition
Describe:
/A
I had physical therapy in the past six months for this
condition
Date of last session:
Januar 2012
I have had diagnostic testing (such as MRI or X-Ray)
due to this condition provide results
I have been to an emergency room or urgent care
center or have been hospitalized in the past 2 years
because of this condition
This condition is resolved without symptoms or pain
for six months or more, I have no restrictions or
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limitations due to this condition and it requires no further
follow up
Date of resolution:
Januar 2012
Diagnosis: An injur , surger or pain (on a regular or intermittent
basis) in relation to, or for an reason sought medical care for the
Hand o W i
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
Location:
Left
Right
Both
I have had more than one episode of this condition in
m lifetime
(which diagnosis (es) and dates)
/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
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Add a symptom
I require medication either daily or as needed for this
condition (Include pain medications)
Please list any medications you are currently taking for
this condition. Separate individual medications with a
comma.
/A
I currently require ongoing medical treatment for this
condition
Describe:
/A
I require a brace or other medical equipment due to
this condition
Describe:
/A
I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery for this condition
Date of surgery:
Januar 2012
I have been told I may need surgery in the future for
this condition
Describe:
/A
I had physical therapy in the past six months for this
condition
Date of last session:
Januar 2012
I have had diagnostic testing (such as MRI or X-Ray)
due to this condition provide results
I have been to an emergency room or urgent care
center or have been hospitalized in the past 2 years
because of this condition
This condition is resolved without symptoms or pain
map.peaceco p .go /MAP/HHF/M
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,I
D
:
Januar 2012
D
)
or Pel is
:A
,
(
,
Hip
P
.
H
/
?
W
P
C
?
D
.
D
27
P
C
?I
,
.
/A
D
:
Januar 2012
L
:
L
R
B
I
(
(
)
)
/A
I
/
S
D
S
: N/A
?
:
Mild
F
:
Dail
D
:
Januar 2012
I
?:
D
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Add a symptom
I require medication either daily or as needed for this
condition (Include pain medications)
Please list any medications you are currently taking for
this condition. Separate individual medications with a
comma.
/A
I currently require ongoing medical treatment for this
condition
Describe:
/A
I require a brace or other medical equipment due to
this condition
Describe:
/A
I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery for this condition
Date of surgery:
Januar 2012
I have been told I may need surgery in the future for
this condition
Describe:
/A
I had physical therapy in the past six months for this
condition
Date of last session:
Januar 2012
I have had diagnostic testing (such as MRI or X-Ray)
due to this condition provide results
I have been to an emergency room or urgent care
center or have been hospitalized in the past 2 years
because of this condition
This condition is resolved without symptoms or pain
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,I
D
:
Januar 2012
D
:A
)
Foo or Ankle
,
(
,
P
.
H
/
?
W
P
C
?
D
.
D
27
P
C
?I
,
.
/A
D
:
Januar 2012
L
:
L
R
B
I
(
(
)
)
/A
I
/
S
D
S
: N/A
?
:
Mild
F
:
Dail
D
:
Januar 2012
I
?:
D
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Add a symptom
I require medication either daily or as needed for this
condition (Include pain medications)
Please list any medications you are currently taking for
this condition. Separate individual medications with a
comma.
/A
I currently require ongoing medical treatment for this
condition
Describe:
/A
I require a brace or other medical equipment due to
this condition
Describe:
/A
I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery for this condition
Date of surgery:
Januar 2012
I have been told I may need surgery in the future for
this condition
Describe:
/A
I had physical therapy in the past six months for this
condition
Date of last session:
Januar 2012
I have had diagnostic testing (such as MRI or X-Ray)
due to this condition provide results
I have been to an emergency room or urgent care
center or have been hospitalized in the past 2 years
because of this condition
This condition is resolved without symptoms or pain
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,I
D
:
Januar 2012
D
)
Elbo
:A
,
(
,
P
.
H
/
?
W
P
C
?
D
.
D
27
P
C
?I
,
.
/A
D
:
Januar 2012
L
:
L
R
B
I
(
(
)
)
/A
I
/
S
D
S
: N/A
?
:
Mild
F
:
Dail
D
:
Januar 2012
I
?:
D
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Add a symptom
I require medication either daily or as needed for this
condition (Include pain medications)
Please list any medications you are currently taking for
this condition. Separate individual medications with a
comma.
/A
I currently require ongoing medical treatment for this
condition
Describe:
/A
I require a brace or other medical equipment due to
this condition
Describe:
/A
I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery for this condition
Date of surgery:
Januar 2012
I have been told I may need surgery in the future for
this condition
Describe:
/A
I had physical therapy in the past six months for this
condition
Date of last session:
Januar 2012
I have had diagnostic testing (such as MRI or X-Ray)
due to this condition provide results
I have been to an emergency room or urgent care
center or have been hospitalized in the past 2 years
because of this condition
This condition is resolved without symptoms or pain
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,I
D
:
Januar 2012
D
)
A m
:A
,
(
,
P
.
H
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.
/A
D
:
Januar 2012
L
:
L
R
B
I
(
(
)
)
/A
I
/
S
D
S
: N/A
?
:
Mild
F
:
Dail
D
:
Januar 2012
I
?:
D
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Add a symptom
I require medication either daily or as needed for this
condition (Include pain medications)
Please list any medications you are currently taking for
this condition. Separate individual medications with a
comma.
/A
I currently require ongoing medical treatment for this
condition
Describe:
/A
I require a brace or other medical equipment due to
this condition
Describe:
/A
I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery for this condition
Date of surgery:
Januar 2012
I have been told I may need surgery in the future for
this condition
Describe:
/A
I had physical therapy in the past six months for this
condition
Date of last session:
Januar 2012
I have had diagnostic testing (such as MRI or X-Ray)
due to this condition provide results
I have been to an emergency room or urgent care
center or have been hospitalized in the past 2 years
because of this condition
This condition is resolved without symptoms or pain
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,I
D
:
Januar 2012
D
)
:A
,
(
,
Le
P
.
H
/
?
W
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?
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.
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,
.
/A
D
:
Januar 2012
L
:
L
R
B
I
(
(
)
)
/A
I
/
S
D
S
: N/A
?
:
Mild
F
:
Dail
D
:
Januar 2012
I
?:
D
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map.peaceco p .go /MAP/HHF/M
c lo kele al/Edi
Add a symptom
I require medication either daily or as needed for this
condition (Include pain medications)
Please list any medications you are currently taking for
this condition. Separate individual medications with a
comma.
/A
I currently require ongoing medical treatment for this
condition
Describe:
/A
I require a brace or other medical equipment due to
this condition
Describe:
/A
I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery for this condition
Date of surgery:
Januar 2012
I have been told I may need surgery in the future for
this condition
Describe:
/A
I had physical therapy in the past six months for this
condition
Date of last session:
Januar 2012
I have had diagnostic testing (such as MRI or X-Ray)
due to this condition provide results
I have been to an emergency room or urgent care
center or have been hospitalized in the past 2 years
because of this condition
This condition is resolved without symptoms or pain
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map.peaceco p .go /MAP/HHF/M
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,I
D
:
Januar 2012
D
)
Finge
:A
,
(
,
P
.
H
/
?
W
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C
?
D
.
D
27
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C
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,
.
/A
D
:
Januar 2012
I
(
(
)
)
/A
I
/
S
D
S
: N/A
?
:
Mild
F
:
Dail
D
:
Januar 2012
I
?:
D
A
I
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condition
Describe:
/A
I require a brace or other medical equipment due to
this condition
Describe:
/A
I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery for this condition
Date of surgery:
Januar 2012
I have been told I may need surgery in the future for
this condition
Describe:
/A
I had physical therapy in the past six months for this
condition
Date of last session:
Januar 2012
I have had diagnostic testing (such as MRI or X-Ray)
due to this condition provide results
I have been to an emergency room or urgent care
center or have been hospitalized in the past 2 years
because of this condition
This condition is resolved without symptoms or pain
for six months or more, I have no restrictions or
limitations due to this condition and it requires no further
follow up
Date of resolution:
Januar 2012
Diagnosis: Any injury, surgery or pain (on a regular or intermittent
basis) in relation to, or for any reason sought medical care for the
Toe
Please respond to all of the bullet points below.
How does this condition affect your activities of
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dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have had more than one episode of this condition in
m lifetime
(which diagnosis (es) and dates)
/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I currentl require ongoing medical treatment for this
condition
Describe:
/A
I require a brace or other medical equipment due to
this condition
Describe:
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/A
I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery for this condition
Date of surgery:
Januar 2012
I have been told I may need surgery in the future for
this condition
Describe:
/A
I had physical therapy in the past six months for this
condition
Date of last session:
Januar 2012
I have had diagnostic testing (such as MRI or X-Ray)
due to this condition provide results
I have been to an emergency room or urgent care
center or have been hospitalized in the past 2 years
because of this condition
This condition is resolved without symptoms or pain
for six months or more, I have no restrictions or
limitations due to this condition and it requires no further
follow up
Date of resolution:
Januar 2012
Diagnosis: Any injury, surgery or pain (on a regular or intermittent
basis) in relation to, or for any reason sought medical care for an
other muscle, bone, tendon or ligament
Describe:
/A
Please respond to all of the bullet points below.
How does this condition affect your activities of
daily living/work?
What is your plan for managing any symptoms
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while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have had more than one episode of this condition in
m lifetime
(which diagnosis (es) and dates)
/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I currentl require ongoing medical treatment for this
condition
Describe:
/A
I require a brace or other medical equipment due to
this condition
Describe:
/A
I have functional limitations due to this condition (for
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example: l can t run or squat)
Describe:
/A
I had surgery for this condition
Date of surgery:
Januar 2012
I have been told I may need surgery in the future for
this condition
Describe:
/A
I had physical therapy in the past six months for this
condition
Date of last session:
Januar 2012
I have had diagnostic testing (such as MRI or X-Ray)
due to this condition provide results
I have been to an emergency room or urgent care
center or have been hospitalized in the past 2 years
because of this condition
This condition is resolved without symptoms or pain
for six months or more, I have no restrictions or
limitations due to this condition and it requires no further
follow up
Date of resolution:
Januar 2012
Diagnosis: Gout (If you have already answered questions on this
condition in another body system, do not check this box)
Please respond to all of the bullet points below.
How does this condition affect your activities of
daily living/work?
What is your plan for managing any symptoms
while serving with the Peace Corps?
Describe your response to all treatments
prescribed for this condition.
Do you have any concerns related to this condition
that may impact on your ability to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
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Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition (Include pain medications)
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication in the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
The cause of this condition is known
List:
/A
I have had more than one episode of this condition in
m lifetime
I have had laborator testing (such as uric acid
levels) or diagnostic testing (such as MRI or X-Ra ) in the
past 6 months due to this condition
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
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Diagnosis: Osteoporosis (decreased bone mass with increased
risk for bone fracture)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition (Include pain medications)
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication in the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
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/A
I am post-menopausal
Year of last menses:
Januar 2012
I have had a spontaneous stress fracture in my
lifetime due to this condition
date (s), location (s) of fracture:
/A
I currently require ongoing medical treatment for this
condition, such as periodic injections directly into a joint
Describe:
/A
I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery due to this condition
I have been told I need, or may need, surgery in the
future due to this condition
(Describe):
/A
I have had diagnostic testing (such as an MRI or XRay) in the past 6 months due to this condition
Diagnosis: Osteopenia (low bone mass):
Please respond to all of the bullet points below.
How does this condition affect your activities of
daily living/work?
What is your plan for managing any symptoms
while serving with the Peace Corps?
Describe your response to all treatments
prescribed for this condition.
Do you have any concerns related to this condition
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that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition (Include pain medications)
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication in the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I am post-menopausal
Year of last menses:
Januar 2012
I have had a spontaneous stress fracture in m
lifetime due to this condition
date (s), location (s) of fracture:
/A
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I currently require ongoing medical treatment for this
condition, such as periodic injections directly into a joint
Describe:
/A
I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery due to this condition
I have been told I need, or may need, surgery in the
future due to this condition
(Describe):
/A
I have had diagnostic testing (such as an MRI or XRay) in the past 6 months due to this condition
Diagnosis: Degenerative Disc Disease (changes to the spinal
discs)
Please respond to all of the bullet points below.
How does this condition affect your activities of
daily living/work?
What is your plan for managing any symptoms
while serving with the Peace Corps?
Describe your response to all treatments
prescribed for this condition.
Do you have any concerns related to this condition
that may impact on your ability to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had symptoms due to this condition
Symptom: N/A
Does this symptom affect your daily life?
Severity:
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Mild
Frequency:
Dail
Date of last occurence:
Januar 2012
Is this an ongoing symptom?:
Delete symptom
Add a symptom
I require medication either daily or as needed for this
condition (Include pain medications)
Please list any medications you are currently taking for
this condition. Separate individual medications with a
comma.
/A
My doctor changed my medication in the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I sometimes experience numbness or pain in my leg
or arm because of a compressed nerve in my neck or
back.
I am post-menopausal
Year of last menses:
Januar 2012
I have had a spontaneous stress fracture in my
lifetime due to this condition
date (s), location (s) of fracture:
/A
I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery due to this condition
I have been told I need, or may need, surgery in the
future due to this condition
(Describe):
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/A
I have had diagnostic testing (such as an MRI or XRa ) in the past 6 months due to this condition
Diagnosis: Degenerative Joint Disease (Osteoarthritis)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition (Include pain medications)
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
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/A
My doctor changed my medication in the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I sometimes experience numbness or pain in my leg
or arm because of a compressed nerve in my neck or
back.
I am post-menopausal
Year of last menses:
Januar 2012
I have had a spontaneous stress fracture in my
lifetime due to this condition
date (s), location (s) of fracture:
/A
I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery due to this condition
I have been told I need, or may need, surgery in the
future due to this condition
(Describe):
/A
I have had diagnostic testing (such as an MRI or XRay) in the past 6 months due to this condition
Diagnosis: Scoliosis (curvature of the spine)
Please respond to all of the bullet points below.
How does this condition affect your activities of
daily living/work?
What is your plan for managing any symptoms
while serving with the Peace Corps?
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Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition (Include pain medications)
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication in the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I currentl require ongoing medical treatment for this
condition
Describe:
/A
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I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery due to this condition
I have been told I need, or may need, surgery in the
future due to this condition
(Describe):
/A
I have had physical therapy for this condition
Date of last therapy:
Januar 2012
I have had diagnostic testing (such as an MRI or XRay) in the past 6 months due to this condition
This condition is resolved without symptoms or pain
for six months or more, I have no restrictions or
limitations due to this condition and it requires no further
follow up
Date of resolution:
Januar 2012
Diagnosis: Kyphosis (bowing of the spine)
Please respond to all of the bullet points below.
How does this condition affect your activities of
daily living/work?
What is your plan for managing any symptoms
while serving with the Peace Corps?
Describe your response to all treatments
prescribed for this condition.
Do you have any concerns related to this condition
that may impact on your ability to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had symptoms due to this condition
Symptom: N/A
Does this symptom affect your daily life?
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Severity:
Mild
Frequency:
Dail
Date of last occurence:
Januar 2012
Is this an ongoing symptom?:
Delete symptom
Add a symptom
I require medication either daily or as needed for this
condition (Include pain medications)
Please list any medications you are currently taking for
this condition. Separate individual medications with a
comma.
/A
My doctor changed my medication in the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I currently require ongoing medical treatment for this
condition
Describe:
/A
I have functional limitations due to this condition (for
example: l can t run or squat)
Describe:
/A
I had surgery due to this condition
I have been told I need, or may need, surgery in the
future due to this condition
(Describe):
/A
I have had physical therapy for this condition
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Da e
c lo kele al/Edi
f a
he a
:
Januar 2012
I ha e had diag
Ra ) i he a 6
Thi c di i
f
i
h
i ia i
d e
f
Da e f e
i
i
ic e i g ( ch a a MRI
h d e
hi c di i
e
ed i h
e, I ha e
e ic i
hi c di i
a di e ie
Xai
f
he
:
Januar 2012
Diag
i ed f
i :A
, diag
hich
he a
ed c di i
ha e
gh
P ea e e
d
H
d e
dai
a
f he b
hi c
di i
i i g/
a
i g
e c ibed f
be
affec
a i
f
.
.
ac i i ie
f
a agi g a
e
e
hi c
di i
ha e a
ha
i
i h he Peace C
De c ibe
D
e
iga e
e i
he a 2 ea
?
Wha i
hi e e
c e, b e, e d
h edic
ge
edica a e i
i
c
ce
ac
a
?
ea
.
e a ed
abi i
i h he Peace C
? If
e
,
hi c
e
di i
e 27
h
ea e de c ibe.
/A
I
Da e
a gi e a diag
f diag
i :
i f
Januar 2012
(De c ibe):
N/A
Id
(Da e
he a e f c di i
ca i g
I ha e
bee gi e a diag
i
)
f i i ia
Januar 2012
I ha e/had
S
d e
hi c
di i
: N/A
D e hi
Se e i :
affec
dai
ife?
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
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hi a
g i g
?:
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c lo kele al/Edi
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition (Include pain medications)
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication in the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I currentl require ongoing medical treatment for this
condition (including transfusions)
List medication and describe reason for change:
/A
I have had blood tests or other diagnostic testing
(such as a Ultrasound) in the past ear due to this
condition
I had surger due to this condition
I have been told I need, or ma need, surger in the
future due to this condition
(Describe):
/A
I have had diagnostic testing (such as an MRI or XRa ) in the past 6 months due to this condition
Previous
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c lo kele al/Edi
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Ne t
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Welcome ekehne Log Off
Peace Corps
Home
INFECTIOUS DISEASE
(Conditions of Infectious Process)
In m
lifetime I have been diagnosed with:
Human Immunodeficienc Virus (HIV).
Date of diagnosis:
Januar 2012
When was the last time ou saw a Health Care provider for
this condition?
Januar 2012
Hepatatis C.
Date of diagnosis:
Januar 2012
When was the last time ou saw a Health Care provider for
this condition?
Januar 2012
I have had a positive PPD and completed a full course of medication for
latent Tuberculosis.
Date medication completed
Januar 2012
When was the last time ou saw a Health Care provider for
this condition?
Januar 2012
I have had a positive PPD and have not been treated for Tuberculosis.
Date
Januar 2012
Reason not given treatment
/A
When was the last time ou saw a Health Care provider for
this condition?
Januar 2012
In the past two ears I have seen a Primar Care Ph sician or
Infectious Disease Specialist for an Infectious Disease (If ou're unsure,
map.peacecorps.go /MAP/HHF/Infect/Edit
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c ic he e f
a i
fc
di i
)
I ha e
ee a d c
Di ea e. If chec ed
i a
i he past two ears f
he
e i
be
.
Da e
Rea
Januar 2012
N/A
a
I fec i
De e e
Add a i i
Check all conditions that appl
Diag
hich
ea .
Ac
i :A
ha e
a diag
Se a T a
i ed Di ea e f
gh
edica a e i
i he a
i (chec a
Ge i a He
ha a
e Si
)
e
Da e
Januar 2012
S
hi i
Da e
Januar 2012
G
hea
Da e
Januar 2012
Ch a
dia
Da e
Januar 2012
Cha c
id
Da e
Januar 2012
T ich
ia i
Da e
Januar 2012
C
d
a
Da e
Januar 2012
Diag
i :L
e Di ea e
P ea e e
be
.
H
d
d e
ac i i ie
Wha i
a
f he b
hi c
f dai
di i
a
f
i
affec
i i g/
hi e e
map.peacecorps.go /MAP/HHF/Infect/Edit
e
?
a agi g a
i g
i h he
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Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
Date
Januar 2012
I have/had s mptoms due to this
condition.
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or inhaled
medication either dail or as needed for this
condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
I have had blood tests or other
diagnostic test (such as Ultrasound) in the
past si months due to this condition.
I have other bod s stem(s) involvement
due to this condition (such as joint pain)
It is recommended b m health
professional that I see a ph sician for
speciali ed monitoring or follow up due to
this condition
Describe
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/A
Thi c
di i
i e
ed i h
fo o e a ea , I ha e
e ic i
i ia i
d e
hi
c di i
a di e ie
f he f
Da e f e
i
Januar 2012
Diag
i : He a i i (i f a
a i
(If
ha e a ead a
e ed
e i
c di i
i a
he b d
e ,d
P ea e e
be
.
d
H
a
d e
f he b
hi c
ac i i ie
f dai
Wha i
di i
a
c
hi c
i
affec
f
?
a agi g a
i g
e
e
di i
D
)
i h he
?
De c ibe
ea
e
i i g/
hi e e
Peace C
f he i e )
hi
chec hi b
e
a
e c ibed f
hi
.
ha e a
di i
abi i
Peace C
c
ce
ha
e
a i
e 27
? If
e a ed
h
,
ac
i h he
ea e de c ibe.
/A
Ac al diagno i (check a lea
belo )
one bo
He a i i A
Da e
Januar 2012
He a i i B (Refe
he
di ea e a d NOT
i
i a i
He B e ie )
Da e
Januar 2012
He a i i C
Da e
Januar 2012
Id '
He a i i I had
Da e
map.peacecorps.go /MAP/HHF/Infect/Edit
ha
i d
f
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Januar 2012
The cause of this condition is known and
can be prevented
Describe
/A
I have/had s mptoms due to this
condition.
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or inhaled
medication either dail or as needed for this
condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
I have had blood tests or other
diagnostic test (such as CT Scan or
Ultrasound) in the past si months due to
this condition.
I require regular blood tests to monitor
the status of m liver function
Date of last test
Januar 2012
Sitemap
Introduction
HIPAA Signature
Opening Questions
Allerg
Cardiovascular
Dermatolog
Endocrinolog
map.peacecorps.go /MAP/HHF/Infect/Edit
I have been to an emergenc room or
urgent care center or have been hospitali ed
in the past t o ears due to this condition.
It is recommended b m health
professional that I see a ph sician for
speciali ed monitoring or follow up due to
this condition
Describe
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Ear, Nose, Throat
Gastroenterolog
Rheumatolog and
Immunolog
Neurolog
Musculoskeletal
Infectious Disease
Hematolog
G naecolog
Respirator
Urolog and
Nephrolog
Opthalmolog
Mental Health
Closing Questions
Diagnoses
Verification
Signature
/A
This condition is resolved without
s mptoms fo o e a ea , I have no
restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution
Januar 2012
Diagnosis: An other Infectious Disease condition or
s mptom no p e io l li ed for which ou have sought
medical attention in the pa
o ea (does no include
self limiting conditions such as a cold, flu or simple
infections)
Please respond to all of the bullet points
below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
Ac
al diagno i (check one bo belo )
I was given a diagnosis for
m s mptoms
Date
Januar 2012
List diagnosis
/A
I don't know the name of
condition causing m s mptoms
or I have not been given a
diagnosis
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Date of initial s mptoms
Januar 2012
I have/had s mptoms due to this
condition.
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or inhaled
medication either dail or as needed for this
condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
M doctor changed m medication in the
past three months (either stopped or
started a medication or changed the dosage
of a current medication)
List reason for change
/A
I have had blood tests or other
diagnostic test (such as Ultrasound) in the
past si months due to this condition.
I had surger due to this condition.
I have been told I need, or ma need,
surger in the future due to this condition
Describe
/A
I have been to an emergenc room or
urgent care center or have been hospitali ed
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in the past two ears due to this condition.
It is recommended b m health
professional that I see a ph sician for
speciali ed monitoring or follow up due to
this condition
Describe
/A
This condition is resolved without
s mptoms for over a ear, I have no
restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution
Januar 2012
Previous
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Save
Ne t
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map.peacecorps.gov/MAP/HHF/Hematolog /Edit
Welcome ekehne Log Off
Peace Corps
Home
Have ou had an of these conditions in
(Check all that appl )
our lifetime?
HEMATOLOGY
(Conditions of the Blood)
M
Da e:
pleen ha been emo ed
Januar 2012
Rea on fo
emo al
/A
Plea e e pond o all of he b lle poin
Ho
doe
Wha i
hi condi ion affec
o
o
plan fo managing an
belo .
ac i i ie of dail li ing/ o k?
mp om
hile e
ing
i h he
Peace Co p ?
De c ibe o
e pon e o all
ea men
p e c ibed fo
hi
condi ion.
Do o
ha e an conce n
on o
abili
o e
ela ed o hi condi ion ha ma impac
e 27 mon h
i h he Peace Co p ? If o,
plea e de c ibe.
/A
A G6PD deficienc (if o
E en ial (P ima
Da e of diagno i :
do no kno , do no check hi bo )
) Th omboc hemia
Januar 2012
When
a
he la
ime o
a
a Heal h Ca e p o ide fo
hi condi ion?
a
a Heal h Ca e p o ide fo
hi condi ion?
Januar 2012
Pol c hemia Ve a
Da e of diagno i :
Januar 2012
When
a
he la
ime o
Januar 2012
Agnogenic M eloid Me apla ia
Da e of diagno i :
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Januar 2012
When was the last time ou saw a Health Care provider for this condition?
Januar 2012
M elofibrosis
Date of diagnosis:
Januar 2012
When was the last time ou saw a Health Care provider for this condition?
Januar 2012
Sickle Cell, Thalassemia, Hemoglobin C or SC DISEASE NOT TRAIT
Date of diagnosis:
Januar 2012
When was the last time ou saw a Health Care provider for this condition?
Januar 2012
Hemophilia
Date of diagnosis:
Januar 2012
When was the last time ou saw a Health Care provider for this condition?
Januar 2012
Hemochromatosis
Date of diagnosis:
Januar 2012
When was the last time ou saw a Health Care provider for this condition?
Januar 2012
L mphoma (Hodgkin Disease, Non-Hodgkin L mphomas, Multiple
M eloma)
Date of diagnosis:
Januar 2012
When was the last time ou saw a Health Care provider for this condition?
Januar 2012
Hemol tic Anemia (breakdown of red blood cells due to a
disease process)
Diagnosis: Auto-Immune Hemol tic Anemia
Please respond to all of the bullet points below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the Peace
Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this
condition that ma impact on our abilit to
serve 27 months with the Peace Corps? If
so, please describe.
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
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map.peacecorps.gov/MAP/HHF/Hematolog /Edit
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom:
N/A
Does this s mptom affect our dail
life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or injectable (shots)
medication either dail or as needed for this
condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
I currentl require ongoing medical treatment
for this condition (including transfusions)
Description:
/A
M doctor changed m medication in the past
3 months (either stopped or started a medication
or changed the dosage of a current medication)
List medication and describe reason for change:
/A
I have had blood tests or other diagnostic
testing in the past 6 months due to this condition
I have been to an emergenc room or urgent
care center or have been hospitali ed in the past
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
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2 ears because of this condition
It is recommended b m health professional
that I see a Hematologist for speciali ed
monitoring or follow up for this condition.
Description:
/A
This condition is resolved without s mptoms
for over a ear, I have no restrictions or
limitations due to this condition and it requires no
further follow up
Date of resolution:
Januar 2012
Diagnosis: Hereditar Hemol tic Anemia
Please respond to all of the bullet points below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the Peace
Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this
condition that ma impact on our abilit to
serve 27 months with the Peace Corps? If
so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom:
N/A
Does this s mptom affect our dail
life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
4/24
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map.peacecorps.gov/MAP/HHF/Hematolog /Edit
Add a s mptom
I require oral (b mouth) or injectable (shots)
medication either dail or as needed for this
condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
I currentl require ongoing medical treatment
for this condition (including transfusions)
Description:
/A
M doctor changed m medication in the past
3 months (either stopped or started a medication
or changed the dosage of a current medication)
List medication and describe reason for change:
/A
I have had blood tests or other diagnostic
testing in the past 6 months due to this condition
I have been to an emergenc room or urgent
care center or have been hospitali ed in the past
2 ears because of this condition
It is recommended b m health professional
that I see a Hematologist for speciali ed
monitoring or follow up for this condition.
Description:
/A
This condition is resolved without s mptoms
for over a ear, I have no restrictions or
limitations due to this condition and it requires no
further follow up
Date of resolution:
Januar 2012
Diagnosis: Other Hemol tic Anemia
Please respond to all of the bullet points below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the Peace
Corps?
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
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map.peacecorps.gov/MAP/HHF/Hematolog /Edit
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this
condition that ma impact on our abilit to
serve 27 months with the Peace Corps? If
so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom:
N/A
Does this s mptom affect our dail
life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or injectable (shots)
medication either dail or as needed for this
condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
I currentl require ongoing medical treatment
for this condition (including transfusions)
Description:
/A
M doctor changed m medication in the past
3 months (either stopped or started a medication
or changed the dosage of a current medication)
List medication and describe reason for change:
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
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map.peacecorps.gov/MAP/HHF/Hematolog /Edit
/A
I have had blood tests or other diagnostic
testing in the past 6 months due to this condition
I have been to an emergenc room or urgent
care center or have been hospitali ed in the past
2 ears because of this condition
It is recommended b m health professional
that I see a Hematologist for speciali ed
monitoring or follow up for this condition.
Description:
/A
This condition is resolved without s mptoms
for over a ear, I have no restrictions or
limitations due to this condition and it requires no
further follow up
Date of resolution:
Januar 2012
Diagnosis: A condition that stops the blood from clotting and results in
abnormal or frequent bleeding
Please respond to all of the bullet points below.
How does this condition affect our activities of dail
living/work?
What is our plan for managing an s mptoms while
serving with the Peace Corps?
Describe our response to all treatments prescribed for
this condition.
Do ou have an concerns related to this condition that
ma impact on our abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
I was given a diagnosis for m s mptoms
Date of initial s mptoms
Januar 2012
List diagnosis
/A
I do not know the name of condition causing m s mptoms
or I have not been given a diagnosis
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
7/24
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map.peacecorps.gov/MAP/HHF/Hematolog /Edit
D
Januar 2012
I
/
S
: N/A
D
S
?
:
Mild
F
:
Dail
D
:
Januar 2012
I
?:
D
A
I
P
(
)
(
)
.S
.
/A
I
(
D
)
:
/A
I
(
D
:
)
,
/A
I
D
:
/A
D
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
:
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map.peacecorps.gov/MAP/HHF/Hematolog /Edit
/A
M doctor changed m medication in the past 3 months
(either stopped or started a medication or changed the
dosage of a current medication)
List medication and describe reason for change:
/A
I have had blood tests or other diagnostic testing in the
past 6 months due to this condition
I have been to an emergenc room or urgent care center
or have been hospitali ed in the past 2 ears because of this
condition
It is recommended b m health professional that I see a
Hematologist for speciali ed monitoring or follow up for this
condition.
Description:
/A
This condition is resolved without s mptoms for over a
ear, I have no restrictions or limitations due to this condition
and it requires no further follow up
Date of resolution:
Januar 2012
YOU MUST CHECK ONE OF THE STATEMENTS BELOW
In the past two ears I have seen a Primar Care Ph sician or
Hematologist for a blood condition (If ou are unsure, click here for a list of
conditions)
I have not seen a doctor in the past two ears for an blood
condition.If checked skip all the questions below.
List date(s)/reason(s) for all visits in the past 2 ears
Date
Reason
Januar 2012
N/A
Delete
Add a visit
Please check all conditions that appl .
Diagnosis: Iron Deficienc Anemia
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
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map.peacecorps.gov/MAP/HHF/Hematolog /Edit
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or injectable (shots)
medication either dail or as needed for this condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I am not able to self administer prescribed injections
I follow a special diet due to having this condition
Description:
/A
I currentl require ongoing medical treatment for this
condition (including transfusions)
Description:
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
10/24
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map.peacecorps.gov/MAP/HHF/Hematolog /Edit
/A
M doctor changed m medication in the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I have had blood tests or other diagnostic testing in
the past 6 months due to this condition
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see a Hematologist for speciali ed monitoring or follow up
for this condition.
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Megaloblastic or Pernicious Anemia (B-12 and/or Folate
Deficienc )
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
11/24
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map.peacecorps.gov/MAP/HHF/Hematolog /Edit
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or injectable (shots)
medication either dail or as needed for this condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I am not able to self administer prescribed injections
I follow a special diet due to having this condition
Description:
/A
I currentl require ongoing medical treatment for this
condition (including transfusions)
Description:
/A
M doctor changed m medication in the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I have had blood tests or other diagnostic testing in
the past 6 months due to this condition
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
12/24
1/18/12
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
It is recommended b m health professional that I
see a Hematologist for speciali ed monitoring or follow up
for this condition.
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: Aplastic Anemia (decreased stem cell production)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or injectable (shots)
medication either dail or as needed for this condition
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
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map.peacecorps.gov/MAP/HHF/Hematolog /Edit
P
.S
.
/A
I
I
D
:
/A
I
(
D
)
:
/A
M
3
(
)
L
:
/A
I
6
I
2
I
I
H
D
:
.
/A
T
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D
:
Januar 2012
D
P
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
:A
)
(
.
14/24
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map.peacecorps.gov/MAP/HHF/Hematolog /Edit
How does this condition affect our activities of dail
living/work?
What is our plan for managing an s mptoms while serving
with the Peace Corps?
Describe our response to all treatments prescribed for this
condition.
Do ou have an concerns related to this condition that ma
impact on our abilit to serve 27 months with the Peace
Corps? If so, please describe.
/A
List diagnosis
/A
I was given a diagnosis for m s mptoms
Date of diagnosis:
Januar 2012
(Describe):
/A
I do not know the name of condition causing m s mptoms or or I
have not been given a diagnosis
(Date of initial s mptoms)
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence: Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or injectable (shots) medication either
dail or as needed for this condition
Please list an medications ou are currentl taking for this condition.
Separate individual medications with a comma.
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
15/24
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map.peacecorps.gov/MAP/HHF/Hematolog /Edit
/A
Ia
If
De c i
ab e
i
a
:
e f ad i i e
ecia die d e
e c ibed i jec i
ha i g hi c
di i
/A
Ic e
(i c di g a
De c i i :
e ie
g i g
f i
)
edica
ea
e
f
hi c
di i
/A
M d c
cha ged
edica i
i he a 3
h (ei he
ed
a ed a edica i
cha ged he d age f a c e
edica i )
Li
edica i
a d de c ibe ea
f cha ge:
/A
I ha e had b
d e
h d e
hi c di i
bee
he diag
I ha e bee
a e e ge c
h
i a i ed i he a 2 ea
ic e
beca
i gi
he
ge ca e ce e
e f hi c di i
I i ec
e ded b
hea h
fe i
He a
gi f
ecia i ed
i i g
f
De c i i :
a
ha I ee a
f
hi c
a
6
ha e
di i
.
/A
Thi c di i
i
ha e
e ic i
f he f
Da e f e
i :
e
ed i h
i ia i
d e
hi c
f
di i
e a ea , I
a di e ie
Januar 2012
e a
Diag
e)
Li
i : A e ia ca
diag
ed b b
d
(b eedi g
ce f
i
/A
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
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map.peacecorps.gov/MAP/HHF/Hematolog /Edit
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or injectable (shots)
medication either dail or as needed for this condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I am not able to self administer prescribed injections
I follow a special diet due to having this condition
Description:
/A
I currentl require ongoing medical treatment for this
condition (including transfusions)
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
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Description:
/A
M doctor changed m medication in the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I have had blood tests or other diagnostic testing in
the past 6 months due to this condition
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see a Hematologist for speciali ed monitoring or follow up
for this condition.
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: A bleeding problem due a specific medication
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
18/24
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map.peacecorps.gov/MAP/HHF/Hematolog /Edit
Januar 2012
L
/A
I
/
S
: N/A
D
S
?
:
Mild
F
:
Dail
D
Si emap
:
Januar 2012
I
I
N
V
I
HIPAA S
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,T
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?:
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/A
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:
/A
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)
/A
I
D
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
:
19/24
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map.peacecorps.gov/MAP/HHF/Hematolog /Edit
/A
have heav menstrual c cles that sometimes restrict
m abilit to meet dail life demands
Describe:
/A
M doctor changed m medication in the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I have had blood tests or other diagnostic testing in
the past 6 months due to this condition
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see a Hematologist for speciali ed monitoring or follow up
for this condition.
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: An condition of the Spleen
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
20/24
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map.peacecorps.gov/MAP/HHF/Hematolog /Edit
/A
Date of diagnosis:
Januar 2012
List diagnosis
/A
I do not know the name of condition causing m
s mptoms or or I have not been given a diagnosis
(Date of initial s mptoms)
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication in the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
I have had blood tests or another diagnostic test in
the past 6 months due to this condition
M spleen was/is enlarged and the cause of this is
known
Describe:
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
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map.peacecorps.gov/MAP/HHF/Hematolog /Edit
/A
M spleen was removed
Describe:
Januar 2012
The reason m spleen was removed is known
Describe:
/A
I have had blood tests or other diagnostic testing in
the past 6 months due to this condition
I have been told I need, or ma need, surger in the
future due to this condition
(Describe):
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see a Hematologist for speciali ed monitoring or follow up
for this condition.
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: An other s mptom, diagnosed condition or surger of
the blood not previousl listed for which ou have sought medical
attention in the past 2 ears
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
22/24
1/18/12
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
I was given a diagnosis for m s mptoms
Date of diagnosis:
Januar 2012
(Describe):
/A
I do not know the name of condition causing m
s mptoms or or I have not been given a diagnosis
(Date of initial s mptoms)
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication in the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
List medication and describe reason for change:
/A
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I currentl require ongoing medical treatment for this
condition (including transfusions)
List medication and describe reason for change:
/A
I have had blood tests or other diagnostic testing
(such as an Ultrasound) in the past ear due to this
condition
I had surger due to this condition
I have been told I need, or ma need, surger in the
future due to this condition
(Describe):
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see a Hematologist for speciali ed monitoring or follow up
for this condition.
Description:
/A
This condition is resolved without s mptoms for over
a ear, I have no restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution:
Januar 2012
Previous
map.peacecorps.gov/MAP/HHF/Hematolog /Edit
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Opening Questions
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Closing Questions
Diagnoses
Verification
Signature
CHECK ANY TRUE STATEMENT BELOW
GYNECOLOGY
(Conditions of the Female Breast and Female Reproductive
Tract)
I am male
I am female
The Peace Corps offers routine Mammogram screenings for women who are 50 ears of age or older
during their service. Not all countries have the capabilities to provide routine screening
Mammograms. You must check one option below.
I will be 50 ears of age or older during the time of m Peace Corps service. I would like to
have a routine Mammogram Screening during m service.
I will be 50 ears of age or older during the time of m Peace Corps service. I would like to
waive m routine Mammogram while in service. I reali e that if I have risk factors or if m ph sician is
in disagreement with this decision, I will be offered routine Mammogram screenings.
I will be under 50 ears of age during the time of m Peace Corps service.
I have had a Mammogram
Date NEXT Mammogram is due
Januar , 2012
I'm currentl on birth control
Note: Peace Corps will prescribe generic equivalents for most medications. Some
methods of contraception are not available in man countries. These are noted below.
Oral Contraceptive
List
/A
Seasonale
Depo Provera Injections (Note: It is unlikel Peace Corps will have access to this
method of contraception)
Date of last injection
Januar , 2012
Nuva Ring (Note: it is unlikel Peace Corps will have access to this method of
contraception
Cervical Cap (Note: Peace Corps does not support this method of contraception)
Date of initial use
Januar , 2012
Diaphragm (Note: It is unlikel Peace Corps will have access to replacing a
diaphragm)
Intrauterine Device(IUD)
T pe
/A
map.peacecorps.gov/MAP/HHF/G ne/Edit
1/14
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map.peacecorps.gov/MAP/HHF/G ne/Edit
Da e
fi
e i
Januar , 2012
I
a
(N
Da e
e: Peace C
fi
d e
hi
e h d
fc
ace
i
)
e i
Januar , 2012
Bi h C
bi h c
Pa ch (N
a ch)
e: I i
i e
Peace C
i ha e acce
e aci g a
Da e
Januar , 2012
Na e
f Pa ch
/A
O he
Li
/A
Check all that appl :
I ha e
had a PAP e in m lifetime
I ha e had a PAP e in m lifetime
PAP c
e e
a a d
ab
a a d e
PAP
id
PAP
a ab
I e
i ed a LEEP
I
a
Id
'
ced
HPV (H
HPV
i
PAP i d e
ie af
a a d I had a c
ii e f
I i ec
eca i ed
De c ibe
e
e ded b
i g
f
PAP
c
e i the past 1
a
Pa i
a d bi
ear
a Vi
)
a
hea h
fe i a
d e
he e
ha I ee a G
f
ec
gi f
ece PAP
/A
Da e NEXT PAP i d e
Januar , 2012
I ha e had a b ea
T
e
fi
a
f
ge
i
a
/A
Da e
Januar , 2012
YOU MUST CHECK ONE OF THE STATEMENTS BELOW
I the past two ears I ha e ee a P i a Ca e Ph icia
G ec
gi
c di i
f he fe a e b ea a d/ fe a e e
d c i e ga (If
'e
he e f a i
f c di i
ha
a e ie a i i f
he e
e
f c di i
map.peacecorps.gov/MAP/HHF/G ne/Edit
f
)
a
e, c ic
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I have not seen a doctor in the a
ea for an condition of the female
breast or female reproductive tract. If checked skip all the questions below.
Date
Reason
Januar 2012
N/A
Delete
Add a visit
Diagnosis: Breast Lump
Please respond to all of the bullet points below.
How does this condition affect our activities of dail living/work?
What is our plan for managing an s mptoms while serving with the Peace
Corps?
Describe our response to all treatments prescribed for this condition.
Do ou have an concerns related to this condition that ma impact on our
abilit to serve 27 months with the Peace Corps? If so, please describe.
/A
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence: Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I have had ultrasound test for this condition and i
a
a d e i e f
he f
I have had ultrasound test for this condition and i
a
a
d e
e i ef
he f
I have had surger or biops for this condition and i
ab
a a d e i e f
he f
I have had surger or biops for this condition and i
a
d e
e i ef
he f
I have been told I need, or ma need, surger i he f
to this condition
Describe
ab
a
ei he
a
a ei he
e due
/A
Date
Januar 2012
It is recommended b m health professional that I see a
G necologist for speciali ed monitoring or follow up for this
condition.D NOT chec hi b
f
eg a i i
he d c
i e PAP
Ma
g a
i i
Describe
map.peacecorps.gov/MAP/HHF/G ne/Edit
f
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map.peacecorps.gov/MAP/HHF/G ne/Edit
/A
This condition is resolved without s mptoms f
e a ea , I
have no restrictions or limitations due to this condition and it requires
no further follow up
Date of resolution
Januar 2012
Diagnosis: Fibroc stic Breasts
Please respond to all of the bullet points below.
How does this condition affect our activities of dail living/work?
What is our plan for managing an s mptoms while serving with the Peace
Corps?
Describe our response to all treatments prescribed for this condition.
Do ou have an concerns related to this condition that ma impact on our
abilit to serve 27 months with the Peace Corps? If so, please describe.
/A
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence: Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I have had ultrasound test for this condition and i
a
a d e i e f
he f
I have had ultrasound test for this condition and i
a
a
d e
e i ef
he f
I have had surger or biops for this condition and i
ab
a a d e i e f
he f
I have had surger or biops for this condition and i
a
d e
e i ef
he f
I have been told I need, or ma need, surger i he f
to this condition
Describe
ab
a
ei he
a
a ei he
e due
/A
Date
Januar 2012
It is recommended b m health professional that I see a
G necologist for speciali ed monitoring or follow up for this
condition.D NOT chec hi b
f
eg a i i
he d c
i e PAP
Ma
g a
i i
map.peacecorps.gov/MAP/HHF/G ne/Edit
f
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map.peacecorps.gov/MAP/HHF/G ne/Edit
Describe
/A
This condition is resolved without s mptoms for over a ear, I
have no restrictions or limitations due to this condition and it requires
no further follow up
Date of resolution
Januar 2012
Diagnosis: S mptom: Abnormal Menses (no bleeding,infrequent bleeding,heav
bleeding, or painful bleeding)
Please check all that appl
Please respond to all of the bullet points below.
How does this condition affect our activities of dail living/work?
What is our plan for managing an s mptoms while serving with the Peace
Corps?
Describe our response to all treatments prescribed for this condition.
Do ou have an concerns related to this condition that ma impact on our
abilit to serve 27 months with the Peace Corps? If so, please describe.
/A
No bleeding or menses
Date of initial s mptoms
Januar 2012
Abnormal
Date of last menses
Januar 2012
Heav
Date of last menses
Januar 2012
Painful
Date of last menses
Januar 2012
I was given a diagnosis for m s mptoms
Date of diagnosis:
Januar 2012
List diagnosis
/A
The condition causing m s mptoms is not known and I do not
have a diagnosis
Date of initial s mptoms
Januar 2012
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
map.peacecorps.gov/MAP/HHF/G ne/Edit
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Dail
Date of last occurence: Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or inhaled medication either dail o a
needed for this condition
Please list an medications ou are currentl taking for this condition.
Separate individual medications with a comma.
/A
I am peri-menopausal or menopausal
The cause of m condition is known
Describe
/A
The cause of m condition is not known
I have had blood tests or other diagnostic test (such as
Ultrasound) in he pa
i mon h due to this condition.
I had surger for this condition in he pa
o ea due to this
condition.
Date
Januar 2012
I have been told I need, or ma need, surger in he f
e due to
this condition.
It is recommended b m health professional that I see a
G necologist for speciali ed monitoring or follow up for this
condition.Do NOT check hi bo fo eg la i i
o he doc o fo
o ine PAP o Mammog am i i
Describe
/A
This condition is resolved without s mptoms fo o e a ea , I
have no restrictions or limitations due to this condition and it requires
no further follow up
Date of resolution
Januar 2012
Diagnosis: Pol c stic Ovarian Disease (PCOS)
Please respond to all of the bullet points below.
How does this condition affect our activities of dail living/work?
What is our plan for managing an s mptoms while serving with the Peace
Corps?
Describe our response to all treatments prescribed for this condition.
Do ou have an concerns related to this condition that ma impact on our
abilit to serve 27 months with the Peace Corps? If so, please describe.
/A
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Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence: Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or inhaled medication either dail o a
needed for this condition
Please list an medications ou are currentl taking for this condition.
Separate individual medications with a comma.
/A
M doctor changed m medication within pa 3 mon h (either
stopped or started a medication or changed the dosage of a current
medication)
List medication and describe reason for change
/A
M s mptoms can sometimes affect m abilit to meet m activities
of dail living.
I have had blood tests or other diagnostic test (such as
Ultrasound) in he pa
i mon h due to this condition.
I had surger for this condition in he pa
o ea due to this
condition.
Date
Januar 2012
I have been told I need, or ma need, surger in he f
to this condition
Describe
e due
/A
I have been to an emergenc room or urgent care center or have
been hospitali ed in he pa
o ea due to this condition.
It is recommended b m health professional that I see a
G necologist for speciali ed monitoring or follow up for hi
condi ion(do no check hi fo need fo eg la PAP c eeining
i i )
Describe
/A
Diagnosis: Pelvic Inflammator Disease
map.peacecorps.gov/MAP/HHF/G ne/Edit
7/14
1/18/12
map.peacecorps.gov/MAP/HHF/G ne/Edit
Please respond to all of the bullet points below.
How does this condition affect our activities of dail living/work?
What is our plan for managing an s mptoms while serving with the Peace
Corps?
Describe our response to all treatments prescribed for this condition.
Do ou have an concerns related to this condition that ma impact on our
abilit to serve 27 months with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence: Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or inhaled medication either dail or as
needed for this condition
Please list an medications ou are currentl taking for this condition.
Separate individual medications with a comma.
/A
I have had this condition more than t ice in m lifetime
List dates
/A
I still have pelvic pain because of this condition
I had an abscess (a swollen area containing pus) in m fallopian
tube or ovar because of this condition
I have had blood tests or other diagnostic test (such as
Ultrasound) in the past si months due to this condition.
I had surger for this condition in the past t o ears due to this
condition.
I have been told I need, or ma need, surger in the future due
to this condition
Describe
/A
I have been to an emergenc room or urgent care center or have
been hospitali ed in the past t o ears due to this condition.
It is recommended b m health professional that I see a
map.peacecorps.gov/MAP/HHF/G ne/Edit
8/14
1/18/12
map.peacecorps.gov/MAP/HHF/G ne/Edit
G necologist for speciali ed monitoring or follow up for this
condition.Do NOT check this bo for regular visits to the doctor for
routine PAP or Mammogram visits
Describe
/A
This condition is resolved without s mptoms for over a ear, I
have no restrictions or limitations due to this condition and it requires
no further follow up
Date of resolution
Januar 2012
Diagnosis: Ovarian C st(s)
Please respond to all of the bullet points below.
How does this condition affect our activities of dail living/work?
What is our plan for managing an s mptoms while serving with the Peace
Corps?
Describe our response to all treatments prescribed for this condition.
Do ou have an concerns related to this condition that ma impact on our
abilit to serve 27 months with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence: Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or inhaled medication either dail or as
needed for this condition
Please list an medications ou are currentl taking for this condition.
Separate individual medications with a comma.
/A
M doctor changed m medication within past 3 months(either
stopped or started a medication or changed the dosage of a current
medication)
List medication and describe reason for change
map.peacecorps.gov/MAP/HHF/G ne/Edit
9/14
1/18/12
map.peacecorps.gov/MAP/HHF/G ne/Edit
/A
I have had this condition mo e han once in m lifetime
List dates
/A
I have had blood tests or other diagnostic test (such as
Ultrasound) in he pa
i mon h due to this condition.
I had surger for this condition in he pa
o ea due to this
condition.
I have been told I need, or ma need, surger in he f
e due
to this condition
Describe
/A
I have been to an emergenc room or urgent care center or have
been hospitali ed in he pa
o ea due to this condition.
It is recommended b m health professional that I see a
G necologist for speciali ed monitoring or follow up for this
condition.Do NOT check hi bo fo eg la i i
o he doc o fo
o ine PAP o Mammog am i i
Describe
/A
This condition is resolved without s mptoms fo o e a ea , I
have no restrictions or limitations due to this condition and it requires
no further follow up
Date of resolution
Januar 2012
Diagnosis: Endometriosis (Uterine lining growing outside of uterus)
Please respond to all of the bullet points below.
How does this condition affect our activities of dail living/work?
What is our plan for managing an s mptoms while serving with the Peace
Corps?
Describe our response to all treatments prescribed for this condition.
Do ou have an concerns related to this condition that ma impact on our
abilit to serve 27 months with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition.
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
map.peacecorps.gov/MAP/HHF/G ne/Edit
10/14
1/18/12
map.peacecorps.gov/MAP/HHF/G ne/Edit
Mild
F e
e c :
Dail
Da e
I
f a
cc
hi a
e ce: Januar 2012
g i g
?:
De e e
Add a
I e i e a (b
h)
i ha ed edica i
ei he dail o a needed f
hi c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e
i di id a
edica i
ihac
a.
/A
Ic e
e
ha e
ed G RH ag i
,f e a
e, L
;
e a
e, ed
ge e
e,
a d ge , f e a
e, da a
di i
M d c
cha ged
edica i
i hi pa 3 mon h (ei he
a ed a edica i
cha ged he d age f a c e
edica i )
Li
edica i
a d de c ibe ea
f cha ge
ge i ,
f
hi
f
c
ed
/A
pa
I ha e had b
d e
he diag
i mon h d e
hi c di i .
I had
ge f
hi c di i
I ha e bee
c di i
De c ibe
d I eed,
a
ic e
eed,
(
ge
ch a U
in he f
a
d) i
ed e
he
hi
/A
I ha e bee
i a i ed i
I i ec
ecia i ed
eg la i i
De c ibe
h
a e e ge c
ge ca e ce e
ha e bee
he pa
o ea d e
hi c di i .
e ded b
hea h
fe i a ha I ee a G ec
gi f
i i g
f
f
hi c di i .Do NOT check hi bo fo
o he doc o fo o ine PAP o Mammog am i i
/A
Thi c
e ic i
Da e f e
di i
i e
i ia i
i
ed
d e
ih
hi c
fo o e a ea , I ha e
a di e ie
f he f
di i
Januar 2012
Diag
i i g)
i :E d
P ea e e
d
H
d e
map.peacecorps.gov/MAP/HHF/G ne/Edit
f he b
e
hi c
a
di i
a ia (E ce
i
be
affec
f
i e
ife a i
f he
e i e
.
ac i i ie
f dai
a agi g a
i i g/
hi e e
i g
?
i h he Peace
?
De c ibe
D
e
a
Wha i
C
e ia H
ha e a
e
e
c
ce
a
ea
e a ed
e
e c ibed f
hi c
di i
ha
hi c
di i
a i
ac
.
11/14
1/18/12
map.peacecorps.gov/MAP/HHF/G ne/Edit
abi i
e
e 27
h
i h he Peace C
? If
,
ea e de c ibe.
/A
Da e
f diag
i :
Januar 2012
I ha e/had
d e
S
hi c
di i
.
: N/A
D e hi
Se e i :
affec
dai
ife?
Mild
F e
e c :
Dail
Da e
I
f a
hi a
cc
e ce: Januar 2012
g i g
?:
De e e
Add a
I e i e a (b
h)
i ha ed edica i
ei he dail o a needed f
hi c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e
i di id a
edica i
ihac
a.
/A
Ic e
e
ha e
ed G RH ag i
,f e a
e, L
;
e a
e, ed
ge e
e,
a d ge , f e a
e, da a
di i
M d c
cha ged
edica i
i hi pa 3 mon h (ei he
a ed a edica i
cha ged he d age f a c e
edica i )
Li
edica i
a d de c ibe ea
f cha ge
f
c
ge i ,
f
hi
ed
/A
pa
I ha e had b
d e
he diag
i mon h d e
hi c di i .
I had
ge f
hi c di i
I ha e bee
c di i
De c ibe
d I eed,
a
eed,
ic e
ge
(
ch a U
in he f
a
ed e
d) i
he
hi
/A
I ha e bee
i a i ed i
I i ec
ecia i ed
eg la i i
De c ibe
h
a e e ge c
ge ca e ce e
ha e bee
he pa
o ea d e
hi c di i .
e ded b
hea h
fe i a ha I ee a G ec
gi f
i i g
f
f
hi c di i .Do NOT check hi bo fo
o he doc o fo o ine PAP o Mammog am i i
/A
map.peacecorps.gov/MAP/HHF/G ne/Edit
12/14
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map.peacecorps.gov/MAP/HHF/G ne/Edit
Thi c
e ic i
Da e f e
di i
i e
i ia i
i
ed
d e
ih
hi c
for over a ear, I ha e
a di e ie
f he f
di i
Januar 2012
Diag
i :A
g necological s mptom, diagnosed condition or
g necological surger not previousl listed ha
h
d ha e
a e i
i the past two ears.(E c di g ea i
ea ed e a
a
di ea e)
Actual Diagnosis(chec
P ea e e
d
H
a
d e
C
f he b
hi c
Wha i
e b
e
di i
a
be
i
)
be
affec
f
gh
edica
i ed
.
ac i i ie
f dai
a agi g a
i i g/
hi e e
?
i g
i h he Peace
?
De c ibe
D
e
ha e a
abi i
e
e
c
a
ce
ea
e
e a ed
e 27
e c ibed f
hi c
h
i h he Peace C
fc
di i
ca
hi c
di i
di i
? If
ha
,
hi c
di i
a i
ac
.
ea e de c ibe.
/A
I
Da e
a gi e
f i i ia
a diag
i f
Januar 2012
Li
diag
i
/A
Id
gi e a diag
Da e f i i ia
he
a e
i g
I ha e
bee
i
Januar 2012
I ha e/had
S
d e
.
: N/A
D e hi
Se e i :
affec
dai
ife?
Mild
F e
e c :
Dail
Da e
I
f a
hi a
cc
e ce: Januar 2012
g i g
?:
De e e
Add a
I e i e a (b
h)
i ha ed edica i
ei he dail or as needed f
hi c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e
i di id a
edica i
ihac
a.
/A
map.peacecorps.gov/MAP/HHF/G ne/Edit
13/14
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map.peacecorps.gov/MAP/HHF/G ne/Edit
M doctor changed m medication within pa 3 mon h (either stopped or
started a medication or changed the dosage of a current medication)
List medication and describe reason for change
/A
pa
I have had blood tests or other diagnostic test (such as Ultrasound) in he
i mon h due to this condition.
I had surger for this condition
I have been told I need, or ma need, surger in he f
condition
Describe
e due to this
/A
I have been to an emergenc room or urgent care center or have been
hospitali ed in he pa
o ea due to this condition.
It is recommended b m health professional that I see a G necologist for
speciali ed monitoring or follow up for this condition.Do NOT check hi bo fo
eg la i i
o he doc o fo o ine PAP o Mammog am i i
Describe
/A
This condition is resolved without s mptoms fo o e a ea , I have no
restrictions or limitations due to this condition and it requires no further follow up
Date of resolution
Januar 2012
Previous
map.peacecorps.gov/MAP/HHF/G ne/Edit
Save
Ne t
14/14
1/18/12
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Welcome ekehne Log Off
Peace Corps
Home
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Introduction
HIPAA Signature
Opening Questions
Allerg
Cardiovascular
Dermatolog
Endocrinolog
Ear, Nose, Throat
Gastroenterolog
Rheumatolog and
Immunolog
Neurolog
Musculoskeletal
Infectious Disease
Hematolog
G naecolog
Respirator
Urolog and
Nephrolog
Opthalmolog
Mental Health
Closing Questions
Diagnoses
Verification
Signature
CHECK ANY TRUE STATEMENT BELOW
RESPIRATORY
(Conditions of Breathing and the Lungs)
In m
lifetime I have had:
Chronic Obstructive Pulmonar Disease (COPD)
Date of diagnosis:
Januar 2012
When was the last time ou saw a Health Care provider for this condition?
Januar 2012
Emph sema
Date of diagnosis:
Januar 2012
When was the last time ou saw a Health Care provider for this condition?
Januar 2012
Pulmonar Embolism
Date of diagnosis:
Januar 2012
When was the last time ou saw a Health Care provider for this condition?
Januar 2012
Sarcoidosis of the lungs and take steroids for this condition
Date of diagnosis:
Januar 2012
When was the last time ou saw a Health Care provider for this condition?
Januar 2012
C stic Fibrosis
Date of diagnosis:
Januar 2012
When was the last time ou saw a Health Care provider for this condition?
Januar 2012
YOU MUST CHECK ONE OF THE STATEMENTS BELOW
In the past two ears I have seen a Primar Care Ph sician, Allergist or
Pulmonologist for a lung condition.(If ou're unsure, click here for a list of
conditions)
I have not seen a doctor in the past two ears for an lung condition.
map.peacecorps.go /MAP/HHF/Resp/Edit
Date
Reason
Januar 2012
N/A
Delete
1/13
1/18/12
map.peacecorps.go /MAP/HHF/Resp/Edit
Add a i i
Diagno i : A hma
M A hma i
igge ed b (Check all ha appl ):
Plea e e pond o all of he b lle poin
Ho
doe
hi condi ion affec
o
belo .
ac i i ie of
dail li ing/ o k?
Wha i
o
hile e
ing
plan fo managing an
i h he Peace Co p ?
De c ibe o
e pon e o all
p e c ibed fo
hi condi ion.
Do o
mp om
ha e an conce n
ha ma impac on o
ea men
ela ed o hi condi ion
abili
o e
e 27 mon h
i h he Peace Co p ? If o, plea e de c ibe.
/A
Da e of diagno i :
Januar 2012
E e ci e
Da e of la
mp om
Januar 2012
E
eme ho o cold
Li
/A
Da e of la
mp om
Januar 2012
Li
Animal Dande
igge
/A
Da e of la
mp om
Januar 2012
D
Li
, Mold, and/o Pollen
igge
/A
Da e of la
map.peacecorps.go /MAP/HHF/Resp/Edit
mp om
2/13
1/18/12
map.peacecorps.go /MAP/HHF/Resp/Edit
Januar 2012
Seasonal Changes
Date of last s mptoms
Januar 2012
Other
List triggers
/A
Date of last s mptoms
Januar 2012
I have/had s mptoms due to this
condition.
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or inhaled
medication either dail or as needed for this
condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
M doctor changed m medication in the
past three months (either stopped or
started a medication or changed the dosage
of a current medication)
List reasons
/A
This condition sometimes impacts on m
abilit to perform m activities of dail living
I have another respirator or cardiac
map.peacecorps.go /MAP/HHF/Resp/Edit
3/13
1/18/12
map.peacecorps.go /MAP/HHF/Resp/Edit
diagnosis that contributes to the s mptoms
in this condiditon
M s mptoms wake me up more than
four times per month
I have had diagnostic testing (such as
pulmonar function tests) due to this
condition in the past two ears
I have been to an emergenc room or
urgent care center or have been hospitali ed
in the past five ears because of this
condition.
Date
Januar 2012
It is recommended b m health
professional that I see a Pulmonologist (a
ph sician speciali ed in caring for respirator
conditions) for speciali ed monitoring or
follow up for this condition.
Describe
/A
This condition is intermittent, triggered
b a specific allergen and requires infrequent
use of an inhaler.
This condition is resolved without
s mptoms for over a ear, I have no
restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution
Januar 2012
Diagnosis: Bronchiectasis (widening of the airwa s)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
map.peacecorps.go /MAP/HHF/Resp/Edit
4/13
1/18/12
map.peacecorps.go /MAP/HHF/Resp/Edit
Januar 2012
I have/had s mptoms due to this
condition.
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or inhaled
medication either dail or as needed for this
condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
I have had this condition more than once
in the past five ears
List dates
/A
I have missed work/school more than
once in the past five ears due to this
condition.
I have had diagnostic testing (such as
pulmonar function tests) due to this
condition in the past two ears
I have been to an emergenc room or
urgent care center or have been hospitali ed
in m lifetime because of this condition.
Date
Januar 2012
It is recommended b m health
professional that I see a Pulmonologist (a
ph sician speciali ed in caring for respirator
conditions) for speciali ed monitoring or
follow up for this condition.
This condition is resolved without
map.peacecorps.go /MAP/HHF/Resp/Edit
5/13
1/18/12
map.peacecorps.go /MAP/HHF/Resp/Edit
s mptoms for over a ear, I have no
restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution
Januar 2012
Diagnosis: Pneumonia (inflammation of the lungs)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of of diagnosis
Januar 2012
I have/had s mptoms due to this
condition.
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or inhaled
medication either dail or as needed for this
condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
map.peacecorps.go /MAP/HHF/Resp/Edit
6/13
1/18/12
map.peacecorps.go /MAP/HHF/Resp/Edit
/A
I ha e had hi c di i
i the past five ears
Li da e
e ha
ce
/A
I ha e i ed
ce i the past five
c di i .
/ ch
ears d e
e ha
hi
I ha e had diag
ic e i g ( ch a
a f ci
e
)d e
hi
di i
in the past two ears
c
I ha e bee
a e e ge c
ge ca e ce e
ha e bee h
i a i ed
in m lifetime beca e f hi c di i .
Da e
Januar 2012
I i ec
e ded b
hea h
fe i a ha I ee a P
gi (a
h icia
ecia i ed i ca i g f
e ia
c di i
)f
ecia i ed
i i g
f
f
hi c di i .
Thi c
di i
i e
ed i h
for over a ear, I ha e
e ic i
i ia i
d e
hi
c di i
a di e ie
f he f
Da e f e
i
Januar 2012
c
Diag
a e)
i :P e
P ea e e
H
d
d e
dai
h
a
f he b
hi c
di i
i i g/
a
i g
De c ibe
e c ibed f
D
a i
be
affec
f
g
.
ac i i ie
f
a agi g a
e
e
hi c
di i
c
ce
ac
i h he Peace C
map.peacecorps.go /MAP/HHF/Resp/Edit
i
i h he Peace C
ha e a
ha
e
a
?
Wha i
hi e e
a (Pa ia
a
ea
e
.
e a ed
abi i
? If
?
,
hi c
e
di i
e 27
h
ea e de c ibe.
7/13
1/18/12
map.peacecorps.go /MAP/HHF/Resp/Edit
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this
condition.
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I have had this condition more than once
in m lifetime
List dates
/A
I have another respirator or cardiac
diagnosis that contrubutes to the s mptoms
of this condition.
I have had diagnostic testing (such as Xra ) due to this condition in the past si
months
I had a chest tube due to this condition.
Date of removal
Januar 2012
I had surger due to this condition in the
past ear
I was hospitali ed in the past t o ears
due to this condition
I will need to have specific follow up for
this condition over the ne t three ears
This condition is resolved without
s mptoms for o er a ear, I have no
restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution
map.peacecorps.go /MAP/HHF/Resp/Edit
8/13
1/18/12
map.peacecorps.go /MAP/HHF/Resp/Edit
Januar 2012
Diagnosis: Sleep Apnea
(Do not complete if ou have alread completed
questions on this condition in another bod section)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this
condition.
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require the use of a C-PAP machine
This condition sometimes impacts on m
abilit to perform m activities of dail living.
I have undergone sleep studies in the
past ear
map.peacecorps.go /MAP/HHF/Resp/Edit
9/13
1/18/12
map.peacecorps.go /MAP/HHF/Resp/Edit
It is recommended b m health
professional that I see a Pulmonologist (a
ph sician speciali ed in caring for respirator
conditions) for speciali ed monitoring or
follow up for this condition.
This condition is resolved without
s mptoms for over a ear, I have no
restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution
Januar 2012
Diagnosis: Bacterial or Viral Respirator Infections
Actual Diagnosis
/A
Please respond to all of the bullet points
below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this
condition.
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
map.peacecorps.go /MAP/HHF/Resp/Edit
10/13
1/18/12
map.peacecorps.go /MAP/HHF/Resp/Edit
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I will need to have specific follow up for
this condition over the ne t three ears
Describe wh
/A
This condition is resolved without
s mptoms, I have no restrictions or
limitations due to this condition and it
requires no further follow up
Date of resolution
Januar 2012
Diagnosis: An other Respirator s mptom, condition
or surger not previousl listed for which ou have sought
medical attention in the past two ears
I was given a diagnosis for m s mptoms
Please respond to all of the bullet points
below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the
Peace Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
map.peacecorps.go /MAP/HHF/Resp/Edit
11/13
1/18/12
map.peacecorps.go /MAP/HHF/Resp/Edit
List diagnosis
/A
I do not know the name of condition
causing m s mptoms or I have not been
given a diagnosis
Date of initial s mptoms
Januar 2012
I have/had s mptoms due to this
condition.
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or inhaled
medication either dail or as needed for this
condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
I have had this condition more than once
in m lifetime
List dates
/A
M doctor changed m medicaton in the
past si months (either stopped or started a
medication or changed the dosage of a
current medication)
List reason(s) for change
map.peacecorps.go /MAP/HHF/Resp/Edit
12/13
1/18/12
map.peacecorps.go /MAP/HHF/Resp/Edit
/A
I have missed work/school more than
once in the past one ear due to this
condition.
I have had diagnostic testing (such as
pulmonar function tests) due to this
condition in the past t o ears
I required Nebuli er treatments in the
past ear due to this condition
I had surger due to this condition in the
past t o ears
I am told I need, or ma need, surger
due to this condition in the ne t three ears
List reason(s) for change
/A
Date
Januar 2012
I have been to an emergenc room or
urgent care center or have been hospitali ed
in m lifetime because of this condition.
Date
Januar 2012
It is recommended b m health
professional that I see a Pulmonologist (a
ph sician speciali ed in caring for respirator
conditions) for speciali ed monitoring or
follow up for this condition.
This condition is resolved without
s mptoms for o er a ear, I have no
restrictions or limitations due to this
condition and it requires no further follow up
Date of resolution
Januar 2012
Previous
map.peacecorps.go /MAP/HHF/Resp/Edit
Save
Ne t
13/13
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
Welcome ekehne Log Off
Peace Corps
Home
In m lifetime I have/had:
Sitemap
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HIPAA Signature
Opening Questions
Allerg
Cardiovascular
Dermatolog
Endocrinolog
Ear, Nose, Throat
Gastroenterolog
Rheumatolog and
Immunolog
Neurolog
Musculoskeletal
Infectious Disease
Hematolog
G naecolog
Respirator
Urolog and
Nephrolog
Opthalmolog
Mental Health
Closing Questions
Diagnoses
Verification
Signature
UROLOGY AND NEPHROLOGY
(Conditions of the Urinar Tract, Bladder or
Kidne )
Nephrectom , Solitar or Horseshoe Kidne
Date of diagnosis:
Januar 2012
When was the last time ou saw a health care provider for this condition?
Januar 2012
C stic Diseases of the Kidne
Date of diagnosis:
Januar 2012
When was the last time ou saw a health care provider for this condition?
Januar 2012
Glomerulonephritis
Date of diagnosis:
Januar 2012
When was the last time ou saw a health care provider for this condition?
Januar 2012
Acute
Chronic
Nephritis, Renal Failure
Date of diagnosis:
Januar 2012
When was the last time ou saw a health care provider for this condition?
Januar 2012
Acute
Chronic
YOU MUST CHECK ONE OF THE STATEMENTS BELOW
In the past two ears I have seen a Primar Care Ph sician,
Nephrologist, Urologist or other doctor for a urinar tract, bladder or kidne
condition. (If ou are unsure, click here for a list of condition).
I have not seen a doctor in the past two ears for an urinar tract,
bladder or kidne condition.
List date(s)/reason(s) for all visits in the past 2 ears
Date
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
Reason
1/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
Januar 2012
N/A
Delete
Add a visit
Please check all conditions that appl .
Diagnosis: C stitis (Urinar
Tract Infection, Bladder Infection)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have had this condition more than once in the last 2
ears
List number of times
/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
2/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
/A
I have had blood tests or other diagnostic testing
(such as ultrasound) in the past 6 months due to this
condition
I have been told my symptoms are caused by
interstitial cystitis
I am male and I have an abnormality in the anatomy
of my urinary tract that is the cause of my symptoms
I have/had another disease process (such as Reiter s
syndrome) that causes this condition
I had surgery due to this condition
I have been told I need, or may need, surgery in the
future due to this condition
Describe:
/A
I will need to see a specialist or have specific follow
up for this condition over the next 3 years
Describe:
/A
This condition is resolved without symptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagno i : P o a i i (P o a e Infec ion)
Please respond to all of the bullet points below.
How does this condition affect your activities of
daily living/work?
What is your plan for managing any symptoms
while serving with the Peace Corps?
Describe your response to all treatments
prescribed for this condition.
Do you have any concerns related to this condition
that may impact on your ability to serve 27 months
with the Peace Corps? If so, please describe.
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
3/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
/A
Date of diagnosis:
Januar 2012
I have had this condition more than once in the last 2
years
List number of times
/A
I have/had symptoms due to this condition
Symptom: N/A
Does this symptom affect your daily life?
Severity:
Mild
Frequency:
Dail
Date of last occurence:
Januar 2012
Is this an ongoing symptom?:
Delete symptom
Add a symptom
I require medication either daily or as needed for this
condition
Please list any medications you are currently taking for
this condition. Separate individual medications with a
comma.
/A
I have had blood tests or other diagnostic testing
(such as ultrasound) in the past 6 months due to this
condition
I have been told my symptoms are caused by
interstitial cystitis
I am male and I have an abnormality in the anatomy
of my urinary tract that is the cause of my symptoms
I have/had another disease process (such as Reiter s
syndrome) that causes this condition
I had surgery due to this condition
I have been told I need, or may need, surgery in the
future due to this condition
Describe:
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
4/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
/A
I i eed
ee a
f
hi c di i
e
De c ibe:
ecia i
he e
ha e
3 ea
ecific f
/A
Thi c di i
i e
ed i h
6
h , I ha e
e ic i
hi c di i
a di e ie
f
Da e f e
i :
f
ea
i ia i
he f
a
d e
Januar 2012
Diagno i : U e h i i (Inflamma ion of he U e h a)
P ea e e
H
d
d e
dai
a
f he b
hi c
di i
i i g/
a
i g
De c ibe
e c ibed f
D
a i
be
affec
.
ac i i ie
f
f
a agi g a
i h he Peace C
e
e
hi c
di i
ha e a
ha
i
?
Wha i
hi e e
e
c
ce
ac
a
?
ea
e a ed
abi i
i h he Peace C
? If
e
.
,
hi c
e
di i
e 27
h
ea e de c ibe.
/A
Da e
f diag
i :
Januar 2012
I ha e had hi c
ea
Li
be
di i
e ha
ce i
he a
2
f i e
/A
I ha e/had
S
D e hi
Se e i :
d e
hi c
di i
: N/A
affec
dai
ife?
Mild
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
5/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
Frequency:
Dail
Date of last occurence:
Januar 2012
Is this an ongoing symptom?:
Delete symptom
Add a symptom
I require medication either daily or as needed for this
condition
Please list any medications you are currently taking for
this condition. Separate individual medications with a
comma.
/A
I have had blood tests or other diagnostic testing
(such as ultrasound) in the past 6 months due to this
condition
I have been told my symptoms are caused by
interstitial cystitis
I am male and I have an abnormality in the anatomy
of my urinary tract that is the cause of my symptoms
I have/had another disease process (such as Reiter s
syndrome) that causes this condition
I had surgery due to this condition
I have been told I need, or may need, surgery in the
future due to this condition
Describe:
/A
I will need to see a specialist or have specific follow
up for this condition over the next 3 years
Describe:
/A
This condition is resolved without symptoms for at
least 6 months, I have no restrictions or limitations due
to this condition and it requires no further follow up
Date of resolution:
Januar 2012
Diagnosis: C stocele (weakened, stretched bladder)
Please respond to all of the bullet points below.
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
6/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I have had blood tests or other diagnostic testing
(such as ultrasound) in the past 6 months due to this
condition
I had surger due to this condition
I have been told I need, or ma need, surger in the
future due to this condition
Describe:
/A
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
7/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
I i eed
ee a
f
hi c di i
e
De c ibe:
ecia i
he e
ha e
3 ea
ecific f
/A
Thi c di i
i e
ed i h
6
h , I ha e
e ic i
hi c di i
a di e ie
f
Da e f e
i :
f
ea
i ia i
he f
a
d e
Januar 2012
Diagnosis: Stress Incontinence (loss of urinar
P ea e e
d
H
d e
dai
a
f he b
hi c
di i
i i g/
a
i g
affec
f
.
ac i i ie
f
a agi g a
e
e c ibed f
e
hi c
ha e a
ha
be
i h he Peace C
De c ibe
D
i
?
Wha i
hi e e
e
control)
a i
c
a
di i
e a ed
abi i
i h he Peace C
? If
e
.
ce
ac
?
ea
,
hi c
e
di i
e 27
h
ea e de c ibe.
/A
Da e
f diag
i :
Januar 2012
I ha e/had
d e
S
hi c
di i
: N/A
D e hi
Se e i :
affec
dai
ife?
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
I e ie
c di i
P ea e i a
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
edica i
edica i
ei he dai
a e c
a
e
eeded f
hi
a i gf
8/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
hi c di i
c
a.
. Se a a e i di id a
edica i
iha
/A
I ha e had b
ch a
a
di i
(
c
I had
d e
d) i he
ge
d e
he diag
ic e
6
h d e
a
hi c
i g
hi
di i
I ha e bee
d I eed,
f
e d e
hi c di i
De c ibe:
a
eed,
ge
i
he
/A
I i eed
ee a
f
hi c di i
e
De c ibe:
ecia i
he e
ha e
3 ea
ecific f
/A
Thi c di i
i e
ed i h
6
h , I ha e
e ic i
hi c di i
a di e ie
f
Da e f e
i :
f
ea
i ia i
he f
a
d e
Januar 2012
Diagnosis: Epidid mitis (inflammation or infection of
Epidid mis)
P ea e e
H
d
a
d e
dai
f he b
hi c
i i g/
a
i g
De c ibe
a i
.
ac i i ie
f
a agi g a
i h he Peace C
e
hi c
ha e a
ha
be
affec
f
e
e c ibed f
D
di i
i
?
Wha i
hi e e
e
c
di i
ce
ac
i h he Peace C
a
e
.
e a ed
abi i
? If
?
ea
,
hi c
e
di i
e 27
h
ea e de c ibe.
/A
Da e
f diag
i :
Januar 2012
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
9/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
I ha e/had
S
d e
hi c
di i
: N/A
D e hi
Se e i :
affec
dai
ife?
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
I e i e edica i
ei he dai
a
eeded f
hi
c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e i di id a
edica i
iha
c
a.
/A
I ha e had hi c
ife i e
I had
ge
di i
d e
e ha
hi c
ce i
di i
I ha e bee
d I eed,
f
e d e
hi c di i
De c ibe:
a
eed,
ge
i
he
/A
I i eed
ee a
f
hi c di i
e
De c ibe:
ecia i
he e
ha e
3 ea
ecific f
/A
Thi c di i
i e
ed i h
6
h , I ha e
e ic i
hi c di i
a di e ie
f
Da e f e
i :
f
ea
i ia i
he f
a
d e
Januar 2012
Diagno i : Unde cended Te
P ea e e
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
d
a
icle
f he b
e
i
be
.
10/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have had this condition more than once in the last 2
ears
List number of times
/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I have had blood tests or other diagnostic testing
(such as ultrasound) in the past 6 months due to this
condition
I had surger due to this condition
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
11/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
I ha e bee
d I eed,
f
e d e
hi c di i
De c ibe:
a
eed,
ge
i
he
/A
I i eed
ee a
f
hi c di i
e
De c ibe:
ecia i
he e
ha e
3 ea
ecific f
/A
Thi c di i
i e
ed i h
6
h , I ha e
e ic i
hi c di i
a di e ie
f
Da e f e
i :
f
ea
i ia i
he f
a
d e
Januar 2012
Diagnosis: H drocele (a fluid-filled sac in the scrotum)
P ea e e
H
d
d e
dai
a
f he b
hi c
di i
i i g/
a
i g
De c ibe
e c ibed f
D
a i
be
affec
f
.
ac i i ie
f
a agi g a
i h he Peace C
e
e
hi c
di i
ha e a
ha
i
?
Wha i
hi e e
e
c
ce
ac
a
?
ea
e a ed
abi i
i h he Peace C
? If
e
.
,
hi c
e
di i
e 27
h
ea e de c ibe.
/A
Da e
f diag
i :
Januar 2012
I ha e had hi c
ea
Li
be
di i
e ha
ce i
he a
2
f i e
/A
I ha e/had
S
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
d e
hi c
di i
: N/A
12/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
D e hi
Se e i :
affec
dai
ife?
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
I e i e edica i
ei he dai
a
eeded f
hi
c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e i di id a
edica i
iha
c
a.
/A
I ha e had b
ch a
a
di i
(
c
I had
ge
d e
d) i he
d e
a
he diag
ic e
6
h d e
hi c
i g
hi
di i
I ha e bee
d I eed,
f
e d e
hi c di i
De c ibe:
a
eed,
ge
i
he
/A
I i eed
ee a
f
hi c di i
e
De c ibe:
ecia i
he e
ha e
3 ea
ecific f
/A
Thi c di i
i e
ed i h
6
h , I ha e
e ic i
hi c di i
a di e ie
f
Da e f e
i :
f
ea
i ia i
he f
a
d e
Januar 2012
Diagno i : Spe ma ocele (a l mp o b lge in he c o
P ea e e
H
dai
d
d e
i i g/
Wha i
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
a
f he b
hi c
di i
e
i
affec
be
m)
.
ac i i ie
f
?
a
f
a agi g a
13/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have had this condition more than once in the last 2
ears
List number of times
/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I have had blood tests or other diagnostic testing
(such as ultrasound) in the past 6 months due to this
condition
I had surger due to this condition
I have been told I need, or ma need, surger in the
future due to this condition
Describe:
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
14/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
/A
I i eed
ee a
f
hi c di i
e
De c ibe:
ecia i
he e
ha e
3 ea
ecific f
/A
Thi c di i
i e
ed i h
6
h , I ha e
e ic i
hi c di i
a di e ie
f
Da e f e
i :
f
ea
i ia i
he f
a
d e
Januar 2012
Diagno i : Va iococele (enla ged ein in he c o
P ea e e
H
d
d e
dai
a
f he b
hi c
di i
i i g/
a
i g
De c ibe
e c ibed f
D
a i
be
affec
.
ac i i ie
f
f
a agi g a
i h he Peace C
e
e
hi c
di i
ha e a
ha
i
?
Wha i
hi e e
e
m)
c
ce
ac
a
?
ea
e a ed
abi i
i h he Peace C
? If
e
.
,
hi c
e
di i
e 27
h
ea e de c ibe.
/A
Da e
f diag
i :
Januar 2012
I ha e had hi c
ea
Li
be
di i
e ha
ce i
he a
2
f i e
/A
I ha e/had
S
D e hi
Se e i :
d e
hi c
di i
: N/A
affec
dai
ife?
Mild
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
15/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
I e i e edica i
ei he dai
a
eeded f
hi
c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e i di id a
edica i
iha
c
a.
/A
I ha e had b
ch a
a
di i
(
c
I had
d e
d) i he
ge
d e
he diag
ic e
6
h d e
a
hi c
i g
hi
di i
I ha e bee
d I eed,
f
e d e
hi c di i
De c ibe:
a
eed,
ge
i
he
/A
I i eed
ee a
f
hi c di i
e
De c ibe:
ecia i
he e
ha e
3 ea
ecific f
/A
Thi c di i
i e
ed i h
6
h , I ha e
e ic i
hi c di i
a di e ie
f
Da e f e
i :
f
ea
i ia i
he f
a
d e
Januar 2012
Diagnosis: Testicular Torsion (t isting of the spermatic cord)
P ea e e
H
d
d e
dai
a
f he b
hi c
di i
i i g/
Wha i
hi e e
De c ibe
e c ibed f
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
i
be
affec
.
ac i i ie
f
?
a
i g
e
f
a agi g a
i h he Peace C
e
e
hi c
di i
a
?
ea
e
.
16/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
I have had this condition more than once in the last 2
ears
List number of times
/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I have had blood tests or other diagnostic testing
(such as ultrasound) in the past 6 months due to this
condition
I had surger due to this condition
I have been told I need, or ma need, surger in the
future due to this condition
Describe:
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
17/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
/A
I i eed
ee a
f
hi c di i
e
De c ibe:
ecia i
he e
ha e
3 ea
ecific f
/A
Thi c di i
i e
ed i h
6
h , I ha e
e ic i
hi c di i
a di e ie
f
Da e f e
i :
f
ea
i ia i
he f
a
d e
Januar 2012
Diagnosis: Kidne
P ea e e
H
and/or Urethral Stones
d
d e
dai
a
f he b
hi c
di i
i i g/
a
i g
De c ibe
a i
affec
f
.
ac i i ie
f
a agi g a
e
e
hi c
di i
ha e a
ha
be
i h he Peace C
e c ibed f
D
i
?
Wha i
hi e e
e
c
ce
ac
a
?
ea
e a ed
abi i
i h he Peace C
? If
e
.
,
hi c
e
di i
e 27
h
ea e de c ibe.
/A
Kid e ( ) affec ed
Lef
Righ
B h
U e e ( ) affec ed
Lef
Righ
B h
Da e f diag
i :
Januar 2012
I ha e had hi c
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
di i
e ha
ce i
18/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
ife i e
(Li da e ):
/A
I ha e/had
S
d e
hi c
di i
: N/A
D e hi
Se e i :
affec
dai
ife?
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
I e i e edica i
ei he dai
a
eeded f
hi
c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e i di id a
edica i
iha
c
a.
/A
I ha e had b
d e
ch a CT Sca ) i he
di i
(
c
I had
ge
d e
a
6
he diag
ic e i g
h d e
hi
hi c
I ha e bee
d I eed,
f
e d e
hi c di i
De c ibe:
di i
a
eed,
ge
i
he
/A
I i eed
ee a
f
hi c di i
e
De c ibe:
ecia i
he e
ha e
3 ea
ecific f
/A
Thi c di i
i e
ed i h
6
h , I ha e
e ic i
hi c di i
a di e ie
f
Da e f e
i :
ea
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
f
i ia i
he f
a
d e
19/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
Januar 2012
Diagno i : U e h al S ic
e (Ob
c ion)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Ureter(s) affected
Left
Right
Both
Date of diagnosis:
Januar 2012
I have had this condition more than once in m
lifetime
(List dates):
/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
20/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
P ea e i a
edica i
a e c e
hi c di i . Se a a e i di id a
edica i
c
a.
a i gf
iha
/A
I ha e had b
d e
ch a CT Sca ) i he
di i
(
c
I had
ge
a
d e
he diag
ic e i g
h d e
hi
6
hi c
di i
I ha e bee
d I eed,
f
e d e
hi c di i
De c ibe:
a
eed,
ge
i
he
/A
I i eed
ee a
f
hi c di i
e
De c ibe:
ecia i
he e
ha e
3 ea
ecific f
/A
Thi c di i
i e
ed i h
6
h , I ha e
e ic i
hi c di i
a di e ie
f
Da e f e
i :
f
ea
i ia i
he f
a
d e
Januar 2012
Diagnosis: P elonephritis (infection of the kidne
ureters)
P ea e e
H
d
a
d e
dai
hi c
i i g/
di i
a
hi e e
i g
De c ibe
e c ibed f
a i
i
be
affec
.
ac i i ie
f
f
a agi g a
i h he Peace C
e
e
hi c
di i
ha e a
ha
e
?
Wha i
D
f he b
and/or
c
ce
ac
i h he Peace C
a
ea
e
.
e a ed
abi i
? If
?
,
hi c
e
di i
e 27
h
ea e de c ibe.
/A
Kid e ( ) affec ed
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
21/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
Left
Right
Both
Ureter(s) affected
Left
Right
Both
Date of diagnosis:
Januar 2012
I have had this condition more than once in m
lifetime
(List dates):
/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M blood pressure is higher than normal due to this
condition
I have had blood tests or other diagnostic testing
(such as CT Scan) in the past 6 months due to this
condition
I had surger due to this condition
I have been told I need, or ma need, surger in the
future due to this condition
Describe:
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
22/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
/A
I i eed
ee a
f
hi c di i
e
De c ibe:
ecia i
he e
ha e
3 ea
ecific f
/A
Thi c di i
i e
ed i h
6
h , I ha e
e ic i
hi c di i
a di e ie
f
Da e f e
i :
f
ea
i ia i
he f
a
d e
Januar 2012
Diagnosis: Benign Prostatic H pertroph (BPH) (enlargement
of the prostate gland)
P ea e e
d
H
d e
dai
a
f he b
hi c
di i
i i g/
a
i g
affec
f
.
ac i i ie
f
a agi g a
e
e c ibed f
e
hi c
ha e a
ha
be
i h he Peace C
De c ibe
D
i
?
Wha i
hi e e
e
a i
c
a
di i
ce
ac
?
ea
.
e a ed
abi i
i h he Peace C
? If
e
,
hi c
e
di i
e 27
h
ea e de c ibe.
/A
Da e
f diag
i :
Januar 2012
I ha e/had
S
d e
hi c
di i
: N/A
D e hi
Se e i :
affec
dai
ife?
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
23/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
Add a
I e i e edica i
ei he dai
a
eeded f
hi
c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e i di id a
edica i
iha
c
a.
/A
I ha e had b
ch a a U a
di i
(
c
I had
ge
d e
d) i
d e
he diag
a 6
he
hi c
ic e i g
h d e
hi
di i
I ha e bee
d I eed,
f
e d e
hi c di i
De c ibe:
a
eed,
ge
i
he
/A
I i eed
ee a
f
hi c di i
e
De c ibe:
ecia i
he e
ha e
3 ea
ecific f
/A
Thi c di i
i e
ed i h
6
h , I ha e
e ic i
hi c di i
a di e ie
f
Da e f e
i :
f
ea
i ia i
he f
a
d e
Januar 2012
Diagnosis: An other Kidne , Bladder, Urinar Tract s mptom,
condition or surger of the Genitourinar s stem not previousl
listed for which ou have sought medical attention in the past 2
ears
P ea e e
H
d
d e
dai
a
f he b
hi c
di i
i i g/
a
i g
De c ibe
e c ibed f
D
a i
affec
f
.
ac i i ie
f
a agi g a
e
e
hi c
di i
c
ce
ac
i h he Peace C
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
be
i h he Peace C
ha e a
ha
i
?
Wha i
hi e e
e
a
ea
e
.
e a ed
abi i
? If
?
,
hi c
e
di i
e 27
h
ea e de c ibe.
24/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
/A
I was given a diagnosis for m s mptoms
Date of diagnosis:
Januar 2012
(Describe):
/A
The condition causing m s mptoms is not known and
I do not have a diagnosis
Date of initial s mptoms
Januar 2012
I have had this condition more than once in the last 2
ears
List dates
/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I currentl require ongoing medical treatment for this
condition
(Describe)
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
25/26
1/18/12
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
/A
I ha e had b
d e
ch a CT Sca ) i he
di i
(
c
I had
ge
d e
a
a
6
hi c
I ha e bee
d I eed,
f
e d e
hi c di i
De c ibe:
he diag
h d e
ic e
hi
di i
a
eed,
ge
i
he
/A
I i eed
ee a
f
hi c di i
e
De c ibe:
ecia i
he e
ha e
3 ea
ecific f
/A
Thi c di i
i e
ed i h
6
h , I ha e
e ic i
hi c di i
a di e ie
f
Da e f e
i :
ea
f
i ia i
he f
a
d e
Januar 2012
Previous
map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit
Save
Ne t
26/26
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
Welcome ekehne Log Off
Peace Corps
Home
In m lifetime I have had:
Sitemap
In od c ion
HIPAA Signa
e
Opening Q e ion
Alle g
Ca dio a c la
De ma olog
Endoc inolog
Ea , No e, Th oa
Ga oen e olog
Rhe ma olog and
Imm nolog
Ne olog
M c lo kele al
Infec io
Di ea e
Hema olog
G naecolog
Re pi a o
U olog and
Neph olog
Op halmolog
Men al Heal h
Clo ing Q e ion
Diagno e
Ve ifica ion
Signa
e
OPTHALMOLOGY
(Conditions of the E e)
Mac la Degene a ion
Da e of diagno i :
Januar 2012
When
a
he la
ime o
a
a heal h ca e p o ide fo
hi condi ion?
a
a heal h ca e p o ide fo
hi condi ion?
a
a heal h ca e p o ide fo
hi condi ion?
Januar 2012
La ice Degene a ion
Da e of diagno i :
Januar 2012
When
a
he la
ime o
Januar 2012
He pe Simple Ke a i i
Da e of diagno i :
Januar 2012
When
a
he la
ime o
Januar 2012
I e e
ible Blindne
Plea e e pond o all of he b lle poin
Ho
doe
hi condi ion affec
belo .
o
ac i i ie of dail
li ing/ o k?
Wha i
e
ing
o
plan fo managing an
mp om
hile
i h he Peace Co p ?
De c ibe o
e pon e o all
ea men
p e c ibed fo
hi condi ion.
Do o
ha e an conce n
ma impac on o
abili
ela ed o hi condi ion ha
o e
e 27 mon h
i h he
Peace Co p ? If o, plea e de c ibe.
/A
Da e of diagno i :
Januar 2012
Loca ion:
Lef
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
1/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
Right
Both
I was given a diagnosis for the cause of m irreversible
blindness
(Describe):
/A
The reason for m blindness is not known and I do not
have a diagnosis
I require a special accommodation for this condition
(Describe):
/A
It is recommended b m health professional that I see an
Opthalmologist for speciali ed monitoring or follow up for this
condition.
(Describe):
/A
YOU MUST CHECK ONE OF THE SELECTIONS BELOW
I require prescription e e correction (either glasses or contacts) Note:
Peace Corps does not support and strongl discourages the use of contact
lenses due to conditions of service.
I do not require prescription e e correction.
YOU MUST CHECK ONE OF THE STATEMENTS BELOW
In the past two ears I have seen a Primar Care Ph sician or
Ophthalmolog (e e) specialist for a condition or surgical procedure of the
e es (If ou are unsure, click here for a list of conditions)
I have not seen a doctor in the past two ears for an e e condition.
List date(s)/reason(s) for all visits in the past 2 ears
Date
Reason
Januar 2012
N/A
Delete
Add a visit
Check all conditions or s mptoms that appl
I have had Vision Correction Surger such as Lasik
M surger was at least 3 months ago and I no longer need an
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
2/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
follow up or post operative care
(Date of surger )
Januar 2012
Diagno i : Re inal De achmen
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
Location:
Left
Right
Both
I had surger due to this condition in the past 2 ears
I have Diabetes
I have been told I need, or ma need, surger in the
future due to this condition
(Describe):
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Opthalmologist for speciali ed monitoring or follow
up for this condition.
(Describe):
/A
This condition has been resolved for at least 3
months and I have no current e e sight limitations or
restrictions
Date of diagnosis:
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
3/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
Januar 2012
Diagno i : Re ini i Pigmen o a
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
Location:
Left
Right
Both
I had surger due to this condition in the past 2 ears
I have been told I need, or ma need, surger in the
future due to this condition
(Describe):
/A
I have Diabetes
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Opthalmologist for speciali ed monitoring or follow
up for this condition.
(Describe):
/A
This condition has been resolved for at least 3
months and I have no current e e sight limitations or
restrictions
Date of diagnosis:
Januar 2012
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
4/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
Diagno i : Ca a ac
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
Location:
Left
Right
Both
I do not need surger at this time
I have some limitation with m e esight due to this
condition (such as night blindness)
(Describe):
/A
I have been told I need, or ma need, surger in the
future due to this condition
(Describe):
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Opthalmologist for speciali ed monitoring or follow
up for this condition.
(Describe):
/A
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
5/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
This condition has been resolved for at least 3
months and I have no current e e sight limitations or
restrictions
Date of diagnosis:
Januar 2012
Diagnosis: Cataract Surger
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of surger :
Januar 2012
Location:
Left
Right
Both
I have some limitation with m e esight due to this
condition (such as night blindness)
(Describe):
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Opthalmologist for speciali ed monitoring or follow
up for this condition.
(Describe):
/A
This condition has been resolved for at least 3
months and I have no current e e sight limitations or
restrictions
Date of diagnosis:
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
6/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
Januar 2012
Diagnosis: Blepharitis (inflammation of the e elash follicles)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
Location:
Left
Right
Both
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
7/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
I have had this condition more than once in m
lifetime
(List dates)
/A
I have some limitation with m e esight due to this
condition
(Describe):
/A
I had surger due to this condition
I have been told I need, or ma need, surger in the
future due to this condition
(Describe):
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Opthalmologist for speciali ed monitoring or follow
up for this condition.
(Describe):
/A
This condition has been resolved for at least 3
months and I have no current e e sight limitations or
restrictions
Date of diagnosis:
Januar 2012
Diagno i : Conj nc i i i (inflamma ion of he conj nc i a)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
8/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
/A
Date of diagnosis:
Januar 2012
Location:
Left
Right
Both
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I have had this condition more than once in m
lifetime
(List dates)
/A
I have some limitation with m e esight due to this
condition
(Describe):
/A
I had surger due to this condition
I have been told I need, or ma need, surger in the
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
9/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
future due to this condition
(Describe):
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Opthalmologist for speciali ed monitoring or follow
up for this condition.
(Describe):
/A
This condition has been resolved for at least 3
months and I have no current e e sight limitations or
restrictions
Date of diagnosis:
Januar 2012
Diagnosis: Chala ion (bump on e elid due to blocked gland of
the e e)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
Location:
Left
Right
Both
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
10/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I have had this condition more than once in m
lifetime
(List dates)
/A
I have some limitation with m e esight due to this
condition
(Describe):
/A
I had surger due to this condition
I have been told I need, or ma need, surger in the
future due to this condition
(Describe):
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Opthalmologist for speciali ed monitoring or follow
up for this condition.
(Describe):
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
11/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
/A
This condition has been resolved for at least 3
months and I have no current e e sight limitations or
restrictions
Date of diagnosis:
Januar 2012
Diagnosis: Hordeolum (infection at the base of the e elashes)
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
Location:
Left
Right
Both
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
12/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
I have had this condition more than once in m
lifetime
(List dates)
/A
I have some limitation with m e esight due to this
condition
(Describe):
/A
I had surger due to this condition
I have been told I need, or ma need, surger in the
future due to this condition
(Describe):
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Opthalmologist for speciali ed monitoring or follow
up for this condition.
(Describe):
/A
This condition has been resolved for at least 3
months and I have no current e e sight limitations or
restrictions
Date of diagnosis:
Januar 2012
Diagnosis: Gla coma
Please respond to all of the bullet points below.
How does this condition affect our activities of
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
13/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
Actual Diagnosis: (check one option below)
Open Angled Glaucoma
Closed Angled Glaucoma
I am not sure which t pe of Glaucoma
Location:
Left
Right
Both
I know the cause of m Glaucoma
(Describe):
/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
14/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
/A
M doctor changed m medication within the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
(List medication and describe reason for change)
/A
M glaucoma was caused b using steroids and is
now resolved
I have had an intraocular pressure reading in the
past 6 months that was normal
I have had an intraocular pressure reading in the
past 6 months that was high
I have some limitation with m e esight due to this
condition
(Describe):
/A
I had surger due to this condition in the past 2 ears
I have been told I need, or ma need, surger in the
future due to this condition
(Describe):
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Opthalmologist for speciali ed monitoring or follow
up for this condition.
(Describe):
/A
This condition has been resolved for at least 3
months and I have no current e e sight limitations or
restrictions
Date of diagnosis:
Januar 2012
Diagnosis: Uveitis (inflammation of the e e)
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
15/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
Please respond to all of the bullet points below.
How does this condition affect our activities of
dail living/work?
What is our plan for managing an s mptoms
while serving with the Peace Corps?
Describe our response to all treatments
prescribed for this condition.
Do ou have an concerns related to this condition
that ma impact on our abilit to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
Location:
Left
Right
Both
M condition was caused b a traumatic event (such
as being hit in the e e)
(Describe):
/A
M condition was not caused b a traumatic event
Date of the event:
Januar 2012
M condition was caused b another disease process
I have
(Describe):
/A
I have/had s mptoms due to this condition
S mptom: N/A
Does this s mptom affect our dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
16/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
Add a s mptom
I require medication either dail or as needed for this
condition
Please list an medications ou are currentl taking for
this condition. Separate individual medications with a
comma.
/A
M doctor changed m medication within the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
(List medication and describe reason for change)
/A
I have some limitation with m e esight due to this
condition
(Describe):
/A
I have had this condition more than once in m
lifetime
I had surger due to this condition in the past 2 ears
I have been told I need, or ma need, surger in the
future due to this condition
(Describe):
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Opthalmologist for speciali ed monitoring or follow
up for this condition.
(Describe):
/A
This condition has been resolved for at least 3
months and I have no current e e sight limitations or
restrictions
Date of diagnosis:
Januar 2012
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
17/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
Diagnosis: Optic Ner e Disease
Please respond to all of the bullet points below.
How does this condition affect your activities of
daily living/work?
What is your plan for managing any symptoms
while serving with the Peace Corps?
Describe your response to all treatments
prescribed for this condition.
Do you have any concerns related to this condition
that may impact on your ability to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
Location:
Left
Right
Both
I was given the cause of my optic nerve condition
(Describe):
/A
I do not know the cause of my optic nerve condition
I have/had symptoms due to this condition
Symptom: N/A
Does this symptom affect your daily life?
Severity:
Mild
Frequency:
Dail
Date of last occurence:
Januar 2012
Is this an ongoing symptom?:
Delete symptom
Add a symptom
I require medication {either oral (by mouth), eye
drops or intravenously (through a needle directly into the
blood stream) either daily or as needed for this
condition
Please list any medications you are currently taking for
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
18/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
this condition. Separate individual medications with a
comma.
/A
I have had this condition more than once in m
lifetime
List dates
/A
M doctor changed m medication within the past 3
months (either stopped or started a medication or
changed the dosage of a current medication)
(List medication and describe reason for change)
/A
I have some limitation with m e esight due to this
condition
(Describe):
/A
I had surger due to this condition in the past 2 ears
I have been told I need, or ma need, surger in the
future due to this condition
(Describe):
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Opthalmologist for speciali ed monitoring or follow
up for this condition.
(Describe):
/A
This condition has been resolved for at least 3
months and I have no current e e sight limitations or
restrictions
Date of diagnosis:
Januar 2012
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
19/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
Diagnosis: Pter gium (a noncancerous clear growth located on
the top of the e e membrane)
Please respond to all of the bullet points below.
How does this condition affect your activities of
daily living/work?
What is your plan for managing any symptoms
while serving with the Peace Corps?
Describe your response to all treatments
prescribed for this condition.
Do you have any concerns related to this condition
that may impact on your ability to serve 27 months
with the Peace Corps? If so, please describe.
/A
Date of diagnosis:
Januar 2012
Location:
Left
Right
Both
I have/had symptoms due to this condition
Symptom: N/A
Does this symptom affect your daily life?
Severity:
Mild
Frequency:
Dail
Date of last occurence:
Januar 2012
Is this an ongoing symptom?:
Delete symptom
Add a symptom
I require medication{ either oral (by mouth) or eye
drops either daily or as needed for this condition
Please list any medications you are currently taking for
this condition. Separate individual medications with a
comma.
/A
My doctor changed my medication within the past 3
months (either stopped or started a medication or
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
20/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
changed the dosage of a current medication)
(List medication and describe reason for change)
/A
I have some limitation with m e esight due to this
condition
(Describe):
/A
I had surger due to this condition in the past 2 ears
I have had this condition more than once in m
lifetime
List dates
/A
I have been told I need, or ma need, surger in the
future due to this condition
(Describe):
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Opthalmologist for speciali ed monitoring or follow
up for this condition.
(Describe):
/A
This condition has been resolved for at least 3
months and I have no current e e sight limitations or
restrictions
Date of diagnosis:
Januar 2012
Diagnosis: An other e e s mptom, diagnosed condition, or e e
surger not previousl listed for which ou have sought medical
attention in the past 2 ears
Please respond to all of the bullet points below.
How does this condition affect our activities of
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
21/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
daily living/work?
What is your plan for managing any symptoms
while serving with the Peace Corps?
Describe your response to all treatments
prescribed for this condition.
Do you have any concerns related to this condition
that may impact on your ability to serve 27 months
with the Peace Corps? If so, please describe.
/A
I was given a diagnosis for my symptoms
Date of initial symptoms
Januar 2012
List diagnosis
/A
I do not know the name of the condition causing my
symptoms or I have not been given a diagnosis
Date of initial symptoms
Januar 2012
I have/had symptoms due to this condition
Symptom: N/A
Does this symptom affect your daily life?
Severity:
Mild
Frequency:
Dail
Date of last occurence:
Januar 2012
Is this an ongoing symptom?:
Delete symptom
Add a symptom
I require medication{ either oral (by mouth) or eye
drops either daily or as needed for this condition
Please list any medications you are currently taking for
this condition. Separate individual medications with a
comma.
/A
My doctor changed my medication within the past 3
months (either stopped or started a medication or
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
22/23
1/18/12
map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit
changed the dosage of a current medication)
(List medication and describe reason for change)
/A
The cause of this condition is known and can
prevented
I have some limitation with m e esight due to this
condition
(Describe):
/A
I had surger due to this condition in the past 2 ears
I have been told I need, or ma need, surger in the
future due to this condition
(Describe):
/A
I have been to an emergenc room or urgent care
center or have been hospitali ed in the past 2 ears
because of this condition
It is recommended b m health professional that I
see an Opthalmologist for speciali ed monitoring or follow
up for this condition.
(Describe):
/A
This condition has been resolved for at least 3
months and I have no current e e sight limitations or
restrictions
Date of diagnosis:
Januar 2012
Previous
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Ne t
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Welcome e eh e Log Off
Peace C
H
Diag
Si e
a
Introduction
HIPAA Signature
Opening Questions
Allerg
Cardiovascular
Dermatolog
Endocrinolog
Ear, Nose, Throat
Gastroenterolog
Rheumatolog and
Immunolog
Neurolog
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Urolog and
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Opthalmolog
Mental Health
Closing Questions
Diagnoses
Verification
Signature
I
e
i
ife i e I ha e/had:
MENTAL HEALTH
(C
di i
f Me
a Hea h)
P ea e be ca did he a
e i g he
e i
be
.
The e a e a
a ig
e
he e
a be e
i
a ed,
e
ed
i e ce a d c i e, e
e e
e
,
i e i ab e ea e . I
a
c
ie ,
he e i i i ed acce
e e - ai ed e a hea h
fe i a a d
a
ecei e ade a e
f e i i g e a hea h
e
e a hea h eed .
BiPolar Disorder
Date of diagnosis:
Januar 2012
Schi ophreniform Disorder, Schi ophrenia,
Schi oaffective Disorder
Date of diagnosis:
Januar 2012
Hospitali ation for mental health
Date:
Januar 2012
Diagnosis
N/A
Suicide Attempt
Date:
Januar 2012
Course of Treatment
N/A
Self Injurious Behavior such as cutting, scratching, etc
Date of S mptom Onset:
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
1/18
1/18/12
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
Januar 2012
This is an ongoing behavior
Not a current behavior
Last date of Self Injurious Behavior:
Januar 2012
Eating Disorder
Date of S mptom Onset:
Januar 2012
This is an ongoing behavior
Not a current behavior
Date of diagnosis:
Januar 2012
Autism Spectrum Disorder
Date of diagnosis:
Januar 2012
List Diagnosis
N/A
Please respond to all of the bullet points
below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
s mptoms while serving with the Peace
Corps?
Describe our response to all
treatments prescribed for this
condition.
Do ou have an concerns related to
this condition that ma impact on our
abilit to serve 27 months with the
Peace Corps? If so, please describe.
/A
Seasonal Affective Disorder requiring placement in a
countr with adequate sunlight
Please respond to all of the bullet points
below.
How does this condition affect our
activities of dail living/work?
What is our plan for managing an
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
2/18
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map.peacecorps.go /MAP/HHF/MentalHealth/Edit
mp om
hile e
ing
i h he Peace
Co p ?
De c ibe o
ea men
e pon e o all
p e c ibed fo
hi
condi ion.
Do o
ha e an conce n
ela ed o
hi condi ion ha ma impac on o
abili
o e
e 27 mon h
i h he
Peace Co p ? If o, plea e de c ibe.
/A
Alcoholi m o o he
b
ance ab
I ha e been obe fo
Da e of ob ie
e
nde 3 ea
:
Januar 2012
I ha e been f ee f om d
nde 5 ea
Da e of la
g ab
e fo
e:
Januar 2012
F
he
e i
be
hich
ei he ha e
c
e i g i hi he
did
ecei e e a
e e ie ced a
a ed
ge ha
f
e gage i dai
Adj
, ea e chec a
c di i
f
ecei ed e a hea h
a
h ee ea OR ,e e if
hea h c
e i g,
i he a
h ee ea
ha
ee
a d affec ed
abi i
ac i i ie .
Mood/o Affec (fo e ample: Dep e ion, D
men Di o de
i h Dep e ed Mood)
h mia,
Plea e e pond o all of he b lle poin
belo .
Ho
doe
hi condi ion affec
o
ac i i ie of dail li ing/ o k?
Wha i
o
mp om
plan fo managing an
hile e
ing
i h he Peace
Co p ?
De c ibe o
ea men
e pon e o all
p e c ibed fo
hi
condi ion.
Do o
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
ha e an conce n
ela ed o
3/18
1/18/12
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
hi c
di i
abi i
ha
e
Peace C
a i
e 27
? If
ac
h
,
i h he
ea e de c ibe.
/A
Ac
a Diag
i (chec
e b
be
)
I was given a diagnosis for m
s mptoms
Date of Diagnosis:
Januar 2012
Diagnosis
N/A
I do not know the name of condition
causing m s mptoms or I have not been
given a diagnosis
Date of initial s mptoms:
Januar 2012
c
I ha e/had
di i .
S
d e
hi
:
N/A
D e
hi
affec
dai ife?
Se e i :
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
I e i e a (b
h)
i ha ed
edica i
ei he dail or as needed f
hi
c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e i di id a
edica i
ihac
a.
/A
M d c
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
cha ged
edica i
i hi
4/18
1/18/12
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he past 6 months (ei he
ed
a ed
a edica i
cha ged he d age f a
c e
edica i )
Li
edica i
a d de c ibe ea
f
cha ge:
/A
I ecei ed c
e i g b a e a hea h
fe i a i he past 3 ears beca e f
hi c di i
I i eed acce
c
ei gd i g
De c ibe:
e a hea h
ice
e
/A
I
i
i
eed e a hea h
i g d i g e ice
edica i
Thi c
di i
i e
ed i h
for over a ear, I ha e
e ic i
i ia i
d e
hi c
a di e ie
f he f
Da e f e
i :
di i
Januar 2012
I
e
ch a Pa ic A ac , Pa ic Di
de , Ph bia,
Ob e i e C
i e Di
de , Ge e a i ed A ie
Di
de
P ea e e
be
.
d
H
a
d e
f he b
hi c
ac i i ie
f dai
Wha i
C
di i
i
affec
i i g/
a
f
?
a agi g a
hi e e
i g
e
e
i h he Peace
?
De c ibe
ea
c
e
e
di i
D
hi c
a
e c ibed f
hi
.
ha e a
di i
abi i
Peace C
e
c
ce
ha
a i
e 27
? If
e a ed
h
,
ac
i h he
ea e de c ibe.
/A
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
5/18
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I have/had s mptoms due to this
condition.
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or inhaled
medication either dail or as needed for this
condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
M doctor changed m medication within
the past 6 months (either stopped or started
a medication or changed the dosage of a
current medication)
List medication and describe reason for
change:
/A
I received counseling b a mental health
professional in the past 3 ears because of
this condition
I will need access to mental health
counseling during m service
Describe:
/A
I will need mental health medication
monitoring during service
This condition is resolved without
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
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for over a ear, I
D
:
Januar 2012
A
I
D
A
P
,A
M
P
S
D
T
,A
S
D
.
H
/
?
W
P
C
?
D
.
D
27
P
C
?I
,
.
/A
A
D
(
I was given a diagnosis for m
s mptoms
Date of Diagnosis:
)
Januar 2012
Diagnosis
N/A
I do not know the name of condition
causing m s mptoms or I have not been
given a diagnosis
Date of initial s mptoms:
Januar 2012
I
/
.
S
:
N/A
D
S
?
:
Mild
F
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
:
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map.peacecorps.go /MAP/HHF/MentalHealth/Edit
Dail
D
:
Januar 2012
I
?:
D
A
I
(
)
dail or as needed
P
.S
.
/A
M
6
(
)
L
:
/A
I
past 3
ears
I
D
:
/A
I
T
for over a ear, I
D
:
Januar 2012
D
A
,A
)
(
D
:
/H
D
,L
P
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
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be
.
H
d e
hi c
ac i i ie
f dai
Wha i
C
di i
affec
i i g/
a
f
?
a agi g a
hi e e
i g
e
e
i h he Peace
?
De c ibe
ea
c
e
di i
D
hi
.
ha e a
hi c
a
e c ibed f
di i
abi i
ce
ha
e
Peace C
c
e a ed
a i
e 27
? If
ac
h
,
i h he
ea e de c ibe.
/A
Ac
a Diag
i (chec
e b
be
)
I was given a diagnosis for m
s mptoms
Date of Diagnosis:
Januar 2012
Diagnosis
N/A
I do not know the name of condition
causing m s mptoms or I have not been
given a diagnosis
Date of initial s mptoms:
Januar 2012
c
I ha e/had
di i .
S
d e
hi
:
N/A
D e hi
dai ife?
Se e i :
affec
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
9/18
1/18/12
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
I e i e a (b
h)
i ha ed
edica i
ei he dail or as needed f
hi
c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e i di id a
edica i
ihac
a.
/A
M d c
cha ged
edica i
i hi
he a 3
h (ei he
ed
a ed
a edica i
cha ged he d age f a
c e
edica i )
Li
edica i
a d de c ibe ea
f
cha ge:
/A
O e f
edica i
i ed ab e i
Adde a , Ri a i , C ce a
hei ge e ic
e i ae .
I ecei ed c
e i g b a e a hea h
fe i a i he past 3 ears beca e f
hi c di i
I i eed acce
c
ei gd i g
De c ibe:
e a hea h
ice
e
/A
I i eed e a hea h edica i
i i g d i g e ice
Thi c di i
i e
ed i h
for over a ear, I ha e
e ic i
i ia i
d e
hi c
a di e ie
f he f
Da e f e
i :
di i
Januar 2012
Pe
a i C ce
(f e a
e: B de i e
Pe
a i , A ge Ma age e P b e
, Cha e ge
ai ai i g g d
i g ea i
hi
g
cia
ea i
hi
i h he
P ea e e
be
.
H
d
d e
ac i i ie
Wha i
a
f he b
hi c
di i
f dai
a
f
i
affec
i i g/
hi e e
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
e
?
a agi g a
i g
i h he Peace
10/18
1/18/12
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
C
?
De c ibe
ea
c
e
e
di i
D
a
e c ibed f
hi
.
ha e a
hi c
e
di i
abi i
e
Peace C
c
ce
ha
e a ed
a i
e 27
? If
ac
h
,
i h he
ea e de c ibe.
/A
Ac
a Diag
i (chec
e b
be
)
I was given a diagnosis for m
s mptoms
Date of Diagnosis:
Januar 2012
Diagnosis
N/A
I do not know the name of condition
causing m s mptoms or I have not been
given a diagnosis
Date of initial s mptoms:
Januar 2012
c
I ha e/had
di i .
S
d e
hi
:
N/A
D e hi
dai ife?
Se e i :
affec
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
I e i e a (b
h)
i ha ed
edica i
ei he dail or as needed f
hi
c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e i di id a
edica i
ihac
a.
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
11/18
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map.peacecorps.go /MAP/HHF/MentalHealth/Edit
/A
M d c
cha ged
edica i
i hi
he past 6 months (ei he
ed
a ed
a edica i
cha ged he d age f a
c e
edica i )
Li
edica i
a d de c ibe ea
f
cha ge:
/A
I ecei ed c
e i g b a e a hea h
fe i a i he past 3 ears beca e f
hi c di i
I i eed acce
e a hea h
c
ei gd i g
e ice
De c ibe:
/A
I i eed e a hea h edica i
i i g d i g e ice
Thi c di i
i e
ed i h
for over a ear, I ha e
e ic i
i ia i
d e
hi c
a di e ie
f he f
Da e f e
i :
di i
Januar 2012
S b a ce
e a ed
be
a e
,
i
e
ab e (f e a
e: a c h
, i c di g b ac
,
hea
d i
e f i ega
e ci i
d g )
P ea e e
be
.
d
H
d e
ac i i ie
a
f he b
hi c
di i
f dai
Wha i
C
f
?
a agi g a
hi e e
i g
e
e
i h he Peace
?
ea
e
di i
D
hi c
a
e c ibed f
hi
.
ha e a
di i
abi i
Peace C
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
i
affec
i i g/
a
De c ibe
c
e
d g
i g
e
c
ce
ha
a i
e 27
? If
e a ed
h
,
ac
i h he
ea e de c ibe.
12/18
1/18/12
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
/A
Ac
a Diag
i (chec
e b
be
I was given a diagnosis for m
s mptoms
Date of Diagnosis:
)
Januar 2012
Diagnosis
N/A
I do not know the name of condition
causing m s mptoms or I have not been
given a diagnosis
Date of initial s mptoms:
Januar 2012
c
I ha e/had
di i .
S
d e
hi
:
N/A
D e
hi
affec
dai ife?
Se e i :
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
I e i e a (b
h)
i ha ed
edica i
ei he dail or as needed f
hi
c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e i di id a
edica i
ihac
a.
/A
M d c
cha ged
edica i
i hi
he past 6 months (ei he
ed
a ed
a edica i
cha ged he d age f a
c e
edica i )
Li
edica i
a d de c ibe ea
f
cha ge:
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
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/A
I ecei ed c
e i g b a e a hea h
fe i a i he past 3 ears beca e f
hi c di i
Ia c e
i he a
e a hea h
ei g
ha e c
e ed i i he a
i
h .
I i ec
e ded b
hea h
fe i a ha I ee a e a hea h
ide f
ecia i ed
i i g
f
f
hi c di i .
De c ibe:
c
/A
Thi c
di i
i e
ed i h
for over a ear, I ha e
e ic i
i ia i
d e
hi c
a di e ie
f he f
Da e f e
i :
di i
Januar 2012
A
E ce i e Die i g
E ce i e E e ci e(f
e ia, B i ia, Bi gi g a d P gi g)
P ea e e
be
.
d
H
d e
ac i i ie
a
f he b
hi c
di i
f dai
Wha i
C
e:
i
affec
i i g/
a
f
?
a agi g a
hi e e
i g
e
e
i h he Peace
?
De c ibe
ea
c
e
e a
e
di i
D
hi c
a
e c ibed f
hi
.
ha e a
di i
abi i
Peace C
e
c
ce
ha
e 27
? If
e a ed
a i
h
,
ac
i h he
ea e de c ibe.
/A
Ac
a Diag
i (chec
e b
be
)
Anore ia
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
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map.peacecorps.go /MAP/HHF/MentalHealth/Edit
Date of diagnosis:
Januar 2012
Bulimia, Binging and Purging
I do not know the name of condition
causing m s mptoms or I have not been
given a diagnosis
Date of initial s mptoms:
Januar 2012
I have/had s mptoms due to this
condition.
S mptom:
N/A
Does this s mptom affect our
dail life?
Severit :
Mild
Frequenc :
Dail
Date of last occurence:
Januar 2012
Is this an ongoing s mptom?:
Delete s mptom
Add a s mptom
I require oral (b mouth) or inhaled
medication either dail or as needed for this
condition
Please list an medications ou are currentl
taking for this condition. Separate individual
medications with a comma.
/A
M doctor changed m medication within
the past 6 months (either stopped or started
a medication or changed the dosage of a
current medication)
List medication and describe reason for
change:
/A
I received counseling b a mental health
professional in the past 3 ears because of
this condition
I am currentl in therap or mental health
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
15/18
1/18/12
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
c
ei g
ha e c
e ed i i he a
h .
I i ec
e ded b
hea h
fe i a ha I ee a e a hea h
ide f
ecia i ed
i i g
f
f
hi c di i .
De c ibe:
i
/A
Thi c
di i
i e
ed i h
for over a ear, I ha e
e ic i
i ia i
d e
hi c
a di e ie
f he f
Da e f e
i :
di i
Januar 2012
A
e
e i
a hea h
i ed
P ea e e
be
.
diag
d
H
a
d e
f he b
hi c
ac i i ie
f dai
Wha i
C
di i
di i
i
affec
f
?
a agi g a
hi e e
i g
e
e
i h he Peace
?
De c ibe
ea
c
e
i i g/
a
ed c
e
di i
D
hi c
a
e c ibed f
hi
.
ha e a
di i
abi i
Peace C
e
c
ce
ha
a i
e 27
? If
e a ed
h
,
ac
i h he
ea e de c ibe.
/A
Ac
a Diag
i (chec
e b
be
I was given a diagnosis for m
s mptoms
Date of Diagnosis:
)
Januar 2012
Diagnosis
N/A
I do not know the name of condition
causing m s mptoms or I have not been
given a diagnosis
Date of initial s mptoms:
map.peacecorps.go /MAP/HHF/MentalHealth/Edit
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Januar 2012
c
I ha e/had
di i .
S
d e
hi
:
N/A
D e hi
dai ife?
Se e i :
affec
Mild
F e
e c :
Dail
Da e
f a
cc
e ce:
Januar 2012
I
hi a
g i g
?:
De e e
Add a
I e i e a (b
h)
i ha ed
edica i
ei he dail or as needed f
hi
c di i
P ea e i a
edica i
a e c e
a i gf
hi c di i . Se a a e i di id a
edica i
ihac
a.
/A
M d c
cha ged
edica i
i hi
he past 6 months (ei he
ed
a ed
a edica i
cha ged he d age f a
c e
edica i )
Li
edica i
a d de c ibe ea
f
cha ge:
/A
I ecei ed c
e i g b a e a hea h
fe i a i he past 3 ears beca e f
hi c di i
Ia c e
i he a
e a hea h
ei g
ha e c
e ed i i he a
i
h .
I i ec
e ded b
hea h
fe i a ha I ee a e a hea h
ide f
ecia i ed
i i g
f
f
hi c di i .
De c ibe:
c
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/A
This condition is resolved without
s mptoms for over a ear, I have no
restrictions or limitations due to this condition
and it requires no further follow up
Date of resolution:
Januar 2012
Previous
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Ne t
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Welcome ekehne Log Off
Peace Corps
Home
Sitemap
Introduction
HIPAA Signature
Opening Questions
Allerg
Cardiovascular
Dermatolog
Endocrinolog
Ear, Nose, Throat
Gastroenterolog
Rheumatolog and
Immunolog
Neurolog
Musculoskeletal
Infectious Disease
Hematolog
G naecolog
Respirator
Urolog and
Nephrolog
Opthalmolog
Mental Health
Closing Questions
Diagnoses
Verification
Signature
CLOSING QUESTIONS
If ou believe that ou will need an special medical
support in connection with an of the conditions ou have
described in the application to serve as Peace Corps
volunteer, please describe the support ou ma need.
Determinations on requests will be made on a case b
case basis
/A
These questions refer to an conditions for which ou
have not alread provided information.
Do ou have an chronic or active condition(s) for
which ou have not seen a medical professional in the
past two ears but for which ou will require access to
care for this specific condition?
Complete the following for EACH condition:
Condition:
/A
Date of evaluation for this condition:
Januar 2012
Recommended treatment:
/A
Follow up evaluation or diagnostic testing is
recommended:
/A
What support or access to medical care is
required:
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/A
Have ou had surger in our lifetime for which ou
have not seen a medical professional in the past two
ears but for which ou will require access to care for this
specific surgical condition?
Complete the following for EACH condition:
Condition:
/A
Date of evaluation for this condition:
Januar 2012
Recommended treatment:
/A
Follow up evaluation or diagnostic testing is
recommended:
/A
What support or access to medical care is
required:
/A
Have ou been hospitali ed overnight in our lifetime
for which ou have not seen a medical professional in the
past two ears but for which ou will require access to
care for the condition that required hospitali ation?
Complete the following for EACH condition:
Condition:
/A
Date of evaluation for this condition:
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Januar 2012
Rec
e ded
ea
e
:
/A
F
ec
e a a i
e ded:
diag
ic e
i gi
/A
Wha
e i ed:
acce
edica ca e i
/A
Ha e
ai ed a a
a ic i j
(
ehic e
accide
i j
f e a
e) i
ife i e, f
hich
ha e
ee a edica
fe i a i he
a
ea b f
hich
i e i e acce
ca e
ecific f
hi i j
?
C
e e he f
i g f EACH c di i :
C
di i
:
/A
Da e
fe a a i
f
hi c
di i
:
Januar 2012
Rec
e ded
ea
e
:
/A
F
ec
e a a i
e ded:
diag
ic e
i gi
/A
Wha
e i ed:
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acce
edica ca e i
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/A
Do ou have pain that is either ongoing or intermittent
(once in awhile), for which ou have not seen a medical
professional in the past two ears but for which ou will
require access to care specific for this pain?
Complete the following for EACH condition:
Condition:
/A
Date of evaluation for this condition:
Januar 2012
Recommended treatment:
/A
Follow up evaluation or diagnostic testing is
recommended:
/A
What support or access to medical care is
required:
/A
Do ou have a condition that will require the use of
medical equipment, either dail or as needed, should ou
accept an invitation to serve (please check all that appl
even if ou have alread documented this equipment in
the previous questions)
Insulin Pump
C-Pap Machine
Compressive Device
Wheelchair, cane, walker, crutches
Hearing aid
Orthotics
An medical device that requires the use
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of batteries or electricit for maintenance
Previous
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Save
Ne t
5/5
1/18/12
DiagnosisVerification
Peace Corps
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Closing Questions
Diagnoses
Verification
Signature
ID
Question Te t
Ans er
Te t
MusculoSkeletalModel.HadOrthopedicSurgery
I have had
orthopedic
surgery in my
lifetime and
hardware (pins,
rods, joint
replacement for
example) was left
in place.
True
MusculoSkeletalModel.SeenDoctorInLast24Months
In the past two
years I have seen
a Primary Care
Physician,
Orthopedic
Surgeon or other
Health Care
Provider (Physical
Therapist or
Chiropractor for
example) for a
condition of the
Muscle, Bone,
Tendon or
Ligament.(If you
are unsure, click
here for a list of
conditions)
Yes
MusculoSkeletalModel.BackOrSpineAnswers.DateOfDiagnosis
Date of diagnosis: 1/1/2012
MusculoSkeletalModel.BackOrSpineAnswers.HadDiagnosticTesting
I have had
diagnostic testing
(such as MRI or XTrue
Ray) due to this
condition provide
results
MusculoSkeletalModel.BackOrSpineAnswers.HadFunctionalLimitations
I have functional
limitations due to
this condition (for
example: l can t
run or squat)
True
I had physical
MusculoSkeletalModel.BackOrSpineAnswers.HadPhysicalTherapy
therapy in the
past six months
for this condition
True
MusculoSkeletalModel.BackOrSpineAnswers.HadSurgeryInPast2Yrs
I had surgery for
this condition
True
MusculoSkeletalModel.BackOrSpineAnswers.HasSymptoms
I have/had
symptoms due to
this condition
True
MusculoSkeletalModel.BackOrSpineAnswers.MoreThanOnceInLifeTime
I have had more
than one episode
True
of this condition in
my lifetime
MusculoSkeletalModel.BackOrSpineAnswers.NeedSurgeryInFuture
I have been told I
may need surgery
True
in the future for
this condition
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
1/64
1/18/12
DiagnosisVerification
T
M
S
M
.B
O S
A
,I
.N S
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M
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M
.B
O S
A
.O
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T
:A
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),
Back o Spine
P
.
H
/
?
W
P
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?
D
M
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A
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N/A
.
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27
P
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?I
,
.
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
2/64
1/18/12
DiagnosisVerification
MusculoSkeletalModel.BackOrSpineAnswers.RequireMedicalEquipment
I require a brace
or other medical
equipment due to
this condition
True
MusculoSkeletalModel.BackOrSpineAnswers.RequireOngoingTreatment
I currently require
ongoing medical
treatment for this
condition
True
MusculoSkeletalModel.BackOrSpineAnswers.SeenInEmergencyRoom
I have been to an
emergency room
or urgent care
center or have
been hospitalized
in the past 2
years because of
this condition
True
MusculoSkeletalModel.HadOrthopedicSurgery.List
Please list type of
surgery or
surgeries as well
as the date of
surgery, reason
for surgery, and
what hardware
was left in place.
N/A
MusculoSkeletalModel.NeckAnswers.DateOfDiagnosis
Date of diagnosis: 1/1/2012
MusculoSkeletalModel.NeckAnswers.HadDiagnosticTesting
I have had
diagnostic testing
(such as MRI or XTrue
Ray) due to this
condition provide
results
MusculoSkeletalModel.NeckAnswers.HadFunctionalLimitations
I have functional
limitations due to
this condition (for
example: l can t
run or squat)
True
MusculoSkeletalModel.NeckAnswers.HadPhysicalTherapy
I had physical
therapy in the
past six months
for this condition
True
MusculoSkeletalModel.NeckAnswers.HadSurgeryInPast2Yrs
I had surgery for
this condition
True
MusculoSkeletalModel.NeckAnswers.HasSymptoms
I have/had
symptoms due to
this condition
True
MusculoSkeletalModel.NeckAnswers.MoreThanOnceInLifeTime
I have had more
than one episode
True
of this condition in
my lifetime
MusculoSkeletalModel.NeckAnswers.NeedSurgeryInFuture
I have been told I
may need surgery
True
in the future for
this condition
MusculoSkeletalModel.NeckAnswers.NoSymptoms
This condition is
resolved without
symptoms or pain
for six months or
more, I have no
restrictions or
limitations due to
this condition and
it requires no
further follow up
True
MusculoSkeletalModel.NeckAnswers.OpeningQuestion
Diagnosis: Any
injury, surgery or
pain (on a regular
or intermittent
basis) in relation
to, or for any
reason sought
medical care for
the Nec
True
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
3/64
1/18/12
DiagnosisVerification
Please respond to
all of the bullet
points below.
How does
this
condition
affect our
activities of
dail
living/work?
What is
our plan
for
managing
an
s mptoms
while
serving
with the
Peace
Corps?
Describe
MusculoSkeletalModel.NeckAnswers.PersonalStatement
our
response
N/A
to all
treatments
prescribed
for this
condition.
Do ou
have an
concerns
related to
this
condition
that ma
impact on
our abilit
to serve 27
months
with the
Peace
Corps? If
so, please
describe.
MusculoSkeletalModel.NeckAnswers.RequireMedicalEquipment
I require a brace
or other medical
equipment due to
this condition
True
MusculoSkeletalModel.NeckAnswers.RequireOngoingTreatment
I currentl require
ongoing medical
treatment for this
condition
True
I have been to an
MusculoSkeletalModel.NeckAnswers.SeenInEmergenc Room
emergenc room
or urgent care
center or have
been hospitali ed
in the past 2
ears because of
this condition
True
Diagnosis: An
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
4/64
1/18/12
DiagnosisVerification
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Question Te t
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map.peacecorps.go /MAP/HHF/DiagnosisVerification/
5/64
1/18/12
DiagnosisVerification
hi
c
di i
affec
ac i i ie
f
dai
i i g/
?
Wha i
a
f
a agi g
a
hi e
e
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i h he
Peace
C
?
De c ibe
A e g M de .Egg A e g A
e
.Pe
e
aSa e e
e
N/A
a
ea
e
e c ibed
f
hi
c
di i
.
D
ha e a
c
ce
e a ed
hi
c
di i
ha
i
a
ac
abi i
e
e 27
h
i h he
Peace
C
? If
,
ea e
de c ibe.
A e g M de .Egg A e g A
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If I e e ie ce a
eac i ,
ea e
e ie a
e ci i
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If I e e ie ce a
eac i , I ha e
E i-Pe
e c ibed f
e
T
e
i
Mi
Dai
A e g
T
e
e Medica i
If I e e ie ce a
eac i ,
ea e
e i e he
e
f
e - hec
e
edica i
T
e
A e g M de .Mi O Dia
A e g A
e
.E iPe
A e g M de .Mi O Dia
A e g A
e
.O e i gQ e
A e g M de .Mi O Dia
A e g A
e
.O e TheC
P ea e e
a
f he b
i
be
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
e
.
d
6/64
1/18/12
DiagnosisVerification
H
d e
hi
c
di i
affec
ac i i ie
f
dai
i i g/
?
Wha i
a
f
a agi g
a
hi e
e
i g
i h he
Peace
C
?
De c ibe
A e g M de .Mi O Dia
A e g A
e
.Pe
aSa e e
N/A
e
e
a
ea
e
e c ibed
f
hi
c
di i
.
D
ha e a
c
ce
e a ed
hi
c
di i
ha
i
a
ac
abi i
e
e 27
h
i h he
Peace
C
? If
,
ea e
de c ibe.
A e g M de .Mi O Dia
A e g A
e
.P e c i
dA e g A
e
.E iPe
A e g M de .O he F
dA e g A
e
.O e i gQ e
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
dA e g A
e
T
e
If I e e ie ce a
eac i , I ha e
E i-Pe
e c ibed f
e
T
e
i
O he F
A e gie
T
e
e Medica i
If I e e ie ce a
eac i ,
ea e
e i e he
e
f
e - hec
e
edica i
T
e
i
A e g M de .O he F
A e g M de .O he F
If I e e ie ce a
eac i ,
ea e
e ie a
e ci i
.O e TheC
d
P ea e e
a
f he b
i
be
e
.
d
7/64
1/18/12
DiagnosisVerification
i
be
.
H
d e
hi
c
di i
affec
ac i i ie
f
dai
i i g/
?
Wha i
a
f
a agi g
a
hi e
e
i g
i h he
Peace
C
?
De c ibe
A e g M de .O he F
dA e g A
e
.Pe
e
aSa e e
e
N/A
a
ea
e
e c ibed
f
hi
c
di i
.
D
ha e a
c
ce
e a ed
hi
c
di i
ha
i
a
ac
abi i
e
e 27
h
i h he
Peace
C
? If
,
ea e
de c ibe.
A e g M de .O he F
dA e g A
e
.P e c i
i
A e g M de .Pea
A e g A
e
.E iPe
A e g M de .Pea
A e g A
e
.O e i gQ e
A e g M de .Pea
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
A e g A
e
.O e TheC
If I e e ie ce a
eac i ,
ea e
e ie a
T
e
e ci i
If I e e ie ce a
eac i , I ha e
E i-Pe
e c ibed f
e
T
e
i
Pea
A e g
T
e
e Medica i
If I e e ie ce a
eac i ,
ea e
e i e he
e
f
e - hec
e
edica i
T
e
N
8/64
1/18/12
DiagnosisVerification
P ea e e
a
f he b
i
be
e
.
H
d
d e
hi
c
di i
affec
ac i i ie
f
dai
i i g/
?
Wha i
a
f
a agi g
a
hi e
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i h he
Peace
C
?
De c ibe
A e g M de .Pea
A e g A
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aSa e e
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N/A
a
ea
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f
hi
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di i
.
D
ha e a
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ce
e a ed
hi
c
di i
ha
i
a
ac
abi i
e
e 27
h
i h he
Peace
C
? If
,
ea e
de c ibe.
A e g M de .Pea
A e g A
e
.P e c i
e
.E iPe
A e g M de .Pe ici i A e g A
e
.O e i gQ e
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
e
T
e
If I e e ie ce a
eac i , I ha e
E i-Pe
e c ibed f
e
T
e
i
Pe ici i A e g
T
e
e Medica i
If I e e ie ce a
eac i ,
ea e
e i e he
e
f
e - hec
e
edica i
T
e
i
A e g M de .Pe ici i A e g A
A e g M de .Pe ici i A e g A
If I e e ie ce a
eac i ,
ea e
e ie a
e ci i
.O e TheC
9/64
1/18/12
DiagnosisVerification
edica i
P ea e e
a
f he b
i
be
e
.
H
d
d e
hi
c
di i
affec
ac i i ie
f
dai
i i g/
?
Wha i
a
f
a agi g
a
hi e
e
i g
i h he
Peace
C
?
De c ibe
A e g M de .Pe ici i A e g A
e
.Pe
aSa e e
e
e
N/A
a
ea
e
e c ibed
f
hi
c
di i
.
D
ha e a
c
ce
e a ed
hi
c
di i
ha
i
a
ac
abi i
e
e 27
h
i h he
Peace
C
? If
,
ea e
de c ibe.
A e g M de .Pe ici i A e g A
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.P e c i
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A e g M de .She fi hA e g A
e
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A e g M de .She fi hA e g A
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
e
.O e TheC
i
e Medica i
If I e e ie ce a
eac i ,
ea e
e ie a
e ci i
T
e
If I e e ie ce a
eac i , I ha e
E i-Pe
e c ibed f
e
T
e
She fi h A e g
T
e
T
e
If I e e ie ce a
eac i ,
ea e
e i e he
e
f
e - hec
e
10/64
1/18/12
DiagnosisVerification
c
e
edica i
P ea e e
a
f he b
i
be
e
.
H
d
d e
hi
c
di i
affec
ac i i ie
f
dai
i i g/
?
Wha i
a
f
a agi g
a
hi e
e
i g
i h he
Peace
C
?
De c ibe
A e g M de .She fi hA e g A
e
.Pe
aSa e e
N/A
e
e
a
ea
e
e c ibed
f
hi
c
di i
.
D
ha e a
c
ce
e a ed
hi
c
di i
ha
i
a
ac
abi i
e
e 27
h
i h he
Peace
C
? If
,
ea e
de c ibe.
A e g M de .She fi hA e g A
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.P e c i
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A e g M de .S faA e g A
e
.O e i gQ e
A e g M de .Egg A e g A
e
.La
A e g M de .Egg A e g A
e
.O e TheC
A e g M de .Egg A e g A
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.P e c i
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A e g M de .Egg A e g A
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.Reac i
.e
A e g M de .Mi O Dia
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map.peacecorps.go /MAP/HHF/DiagnosisVerification/
A e g A
Reac i
e
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.da e
e Medica i
.i
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e Medica i
.
If I e e ie ce a
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S fa A e g
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Da e f a
eac i
1/1/2012
Li
N/A
Li
N/A
De c ibe
eac i
N/A
Li
N/A
11/64
1/18/12
list
DiagnosisVerification
Allerg Model.MilkOrDiar Allerg Answers.Prescription.list
List
N/A
Allerg Model.OtherFoodAllerg Answers.OverTheCounterMedications.
list
List
N/A
Allerg Model.OtherFoodAllerg Answers.Prescription.list
List
N/A
Allerg Model.PeanutAllerg Answers.OverTheCounterMedications.list
List
N/A
Allerg Model.PeanutAllerg Answers.Prescription.list
List
N/A
Allerg Model.PenicillinAllerg Answers.LastReaction.date
Date of last
reaction
1/1/2012
Allerg Model.PenicillinAllerg Answers.OverTheCounterMedications.
list
List
N/A
Allerg Model.PenicillinAllerg Answers.Prescription.list
List
N/A
Allerg Model.PenicillinAllerg Answers.Reaction.results
Describe our
reaction
N/A
Allerg Model.ShellfishAllerg Answers.LastReaction.date
Date of last
reaction
1/1/2012
Allerg Model.ShellfishAllerg Answers.OverTheCounterMedications.list List
N/A
Allerg Model.ShellfishAllerg Answers.Prescription.list
List
N/A
Allerg Model.ShellfishAllerg Answers.Reaction.results
Describe our
reaction
N/A
Allerg Model.SulfaAllerg Answers.Reaction.results
Describe our
reaction
N/A
Cardiovascular
ID
Question Te
Cardiolog Model.Bloodthinners
Are ou curre
taking a
bloodthining
medication
than aspirin?
Cardiolog Model.Cardiom opath
Cardiom opa
Cardiolog Model.CongestiveHeartFailure
Congestive H
Failure
Cardiolog Model.Coronar Arter Disease
Coronar Art
Disease
Cardiolog Model.EcgInLast6Months
I have had a
electrocardio
in the
months
Cardiolog Model.Endocarditis
Cardiolog Model.HeartAttack
Endocarditis
Heart Attack
Cardiolog Model.HeartDefect
A Heart Defe
present since
birth that req
speciali ed ca
Cardiolog Model.OverFift
I am 50 ear
age or older
Cardiolog Model.Pacemaker
A Pacemaker
Cardiolog Model.Pulmonar Embolism
Pulmonar
Embolism
Cardiolog Model.SeenDoctorInLast24Months
In the past tw
ears I have
a Primar Ca
Ph sician or
Cardiologist f
heart or bloo
vessel condit
Cardiolog Model.Surger
Heart or Majo
Vessel Surge
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
12/64
1/18/12
DiagnosisVerification
Cardiolog Model.Bloodthinners.Meds
Please list o
blood thining
medications.
Separate
individual
medications w
a comma.
Cardiolog Model.Cardiom opath .date
Date of diagn
Cardiolog Model.CongestiveHeartFailure.date
Date of diagn
Cardiolog Model.Coronar Arter Disease.date
Date of diagn
Cardiolog Model.Endocarditis.date
Date of diagn
Cardiolog Model.HeartAttack.date
Date of diagn
Cardiolog Model.HeartDefect.description
Describe:
Cardiolog Model.LowBloodPressureAnswers.ConditionIsStable
This condition
stable, with
normal blood
pressure ove
past ear
Cardiolog Model.LowBloodPressureAnswers.DateOfDiagnosis
Date of diagn
Cardiolog Model.LowBloodPressureAnswers.DiagnosticTestsInLast6Months
I have had te
done in the la
months to
diagnose or
monitor this
condition.
includes lab t
(such as bloo
work) or
radiologic tes
(such as MRI
Echocardiogr
Cardiolog Model.LowBloodPressureAnswers.HasMedications
I require
medication e
dail or as
needed for th
condition
Cardiolog Model.LowBloodPressureAnswers.HasS mptoms
I have/had
s mptoms du
this condition
Cardiolog Model.LowBloodPressureAnswers.Independentl MonitoringBloodPressure
I am
independent
monitoring m
blood pressu
Cardiolog Model.LowBloodPressureAnswers.MedicationChangedInLast3Months
M doctor
changed m
medication w
the past 3 m
(either stopp
started a
medication o
changed the
dosage of a
current
medication)
Cardiolog Model.LowBloodPressureAnswers.Medications
Please list an
medications
are currentl
taking for thi
condition.
Separate
individual
medications w
a comma.
Cardiolog Model.LowBloodPressureAnswers.MonitoringOrFollowupRecommended
It is
recommende
m health
professional
see a Cardio
for speciali e
monitoring or
follow up for
condition
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
13/64
1/18/12
DiagnosisVerification
Cardiolog Model.LowBloodPressureAnswers.OpeningQuestion
Diagnosis: Lo
Blood Pressu
Please respo
all of the bull
points below
Cardiolog Model.LowBloodPressureAnswers.PersonalStatement
Cardiolog Model.LowBloodPressureAnswers.SpecialDietDueToCondition
I follow a spe
diet due to h
this condition
I have been
emergenc ro
or urgent car
center or hav
Cardiolog Model.LowBloodPressureAnswers.VisitedEmergenc RoomOrHospitali edInLast2Years
been hospita
in the past 2
ears becaus
this condition
Cardiolog Model.Pacemaker.date
Date of inser
Cardiolog Model.Pulmonar Embolism.date
Date of diagn
Cardiolog Model.Surger .date
Date of surge
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
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DiagnosisVerification
Cardiolog Model.Surger .date
Date of surge
Cardiolog Model.Surger .t pe
T pe of surge
Cardiolog Model.Cardiom opath .DoctorLastSeen.date
When was th
last time ou
a Health Care
provider for t
condition:
Cardiolog Model.CongestiveHeartFailure.DoctorLastSeen.date
When was th
last time ou
a Health Care
provider for t
condition:
Cardiolog Model.Coronar Arter Diseaser.DoctorLastSeen.date
When was th
last time ou
a Health Care
provider for t
condition:
Cardiolog Model.Endocarditis.DoctorLastSeen.date
When was th
last time ou
a Health Care
provider for t
condition:
Cardiolog Model.HeartAttack.DoctorLastSeen.date
When was th
last time ou
a Health Care
provider for t
condition:
Cardiolog Model.HeartDefect.DoctorLastSeen.date
When was th
last time ou
a Health Care
provider for t
condition:
Cardiolog Model.LowBloodPressureAnswers.MedicationChangedInLast3Months.description
List the
medications t
changed and
describe reas
for change:
Cardiolog Model.LowBloodPressureAnswers.MonitoringOrFollowupRecommended.description
Please descr
an monitorin
follow up
required:
Cardiolog Model.LowBloodPressureAnswers.SpecialDietDueToCondition.description
Describe
Cardiolog Model.LowBloodPressureAnswers.S mptoms.AreAn Ongoing
Cardiolog Model.Pacemaker.DoctorLastSeen.date
When was th
last time ou
a Health Care
provider for t
condition:
Cardiolog Model.Pulmonar Embolism.DoctorLastSeen.date
When was th
last time ou
a Health Care
provider for t
condition:
Cardiolog Model.Surger .DoctorLastSeen.date
When was th
last time ou
a Health Care
provider in
relation to th
surger :
Closing Questions
ID
Question Te t
Ans er
Te t
If ou believe
that ou will
need an
special medical
support in
connection with
an of the
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
15/64
1/18/12
DiagnosisVerification
ClosingQuestionsModel.MedicalSupportDesc
an of the
conditions ou
have described
in the
application to
N/A
serve as Peace
Corps
volunteer,
please describe
the support
ou ma need.
Determinations
on requests
will be made on
a case b case
basis
ClosingQuestionsModel.ChronicConditionsAnswers.Condition
Condition:
N/A
ClosingQuestionsModel.ChronicConditionsAnswers.DateOfEvaluation
Date of
evaluation for
this condition:
1/1/2012
ClosingQuestionsModel.ChronicConditionsAnswers.OpeningQuestion
Do ou have
an chronic or
active
condition(s) for
which ou have
not seen a
medical
professional in
the past two
ears but for
which ou will
require access
to care for this
specific
condition?
True
ClosingQuestionsModel.ChronicConditionsAnswers.RecommendedFollowUp
Follow up
evaluation or
diagnostic
testing is
recommended:
N/A
ClosingQuestionsModel.ChronicConditionsAnswers.RecommendedTreatment
Recommended
treatment:
N/A
ClosingQuestionsModel.ChronicConditionsAnswers.RequiredAccessToMedicalCare
What support
or access to
medical care is
required:
N/A
ClosingQuestionsModel.Equipment.CompressiveDevice
Compressive
Device
True
ClosingQuestionsModel.Equipment.CPapMachine
C-Pap Machine
True
ClosingQuestionsModel.Equipment.HearingAid
Hearing aid
True
ClosingQuestionsModel.Equipment.InsulinPump
Insulin Pump
True
ClosingQuestionsModel.Equipment.Orthotics
Orthotics
True
ClosingQuestionsModel.Equipment.Other
An medical
device that
requires the
use of
batteries or
electricit for
maintenance
True
ClosingQuestionsModel.Equipment.WheelchairEtc
Wheelchair,
cane, walker,
crutches
True
ClosingQuestionsModel.Hospitali ationsAnswers.Condition
Condition:
N/A
ClosingQuestionsModel.Hospitali ationsAnswers.DateOfEvaluation
Date of
evaluation for
this condition:
1/1/2012
Have ou been
hospitali ed
overnight in
our lifetime for
which ou have
not seen a
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
16/64
1/18/12
DiagnosisVerification
ClosingQuestionsModel.Hospitali ationsAnswers.OpeningQuestion
not seen a
medical
professional in
True
the past two
ears but for
which ou will
require access
to care for the
condition that
required
hospitali ation?
ClosingQuestionsModel.Hospitali ationsAnswers.RecommendedFollowUp
Follow up
evaluation or
diagnostic
testing is
recommended:
N/A
ClosingQuestionsModel.Hospitali ationsAnswers.RecommendedTreatment
Recommended
treatment:
N/A
ClosingQuestionsModel.Hospitali ationsAnswers.RequiredAccessToMedicalCare
What support
or access to
medical care is
required:
N/A
ClosingQuestionsModel.OngoingPainAnswers.Condition
Condition:
N/A
ClosingQuestionsModel.OngoingPainAnswers.DateOfEvaluation
Date of
evaluation for
this condition:
1/1/2012
Do ou have
ClosingQuestionsModel.OngoingPainAnswers.OpeningQuestion
ClosingQuestionsModel.OngoingPainAnswers.RecommendedFollowUp
pain that is
either ongoing
or intermittent
(once in
awhile), for
which ou have
not seen a
medical
professional in
the past two
ears but for
which ou will
require access
to care specific
for this pain?
Follow up
evaluation or
diagnostic
testing is
recommended:
True
N/A
ClosingQuestionsModel.OngoingPainAnswers.RecommendedTreatment
Recommended
treatment:
N/A
ClosingQuestionsModel.OngoingPainAnswers.RequiredAccessToMedicalCare
What support
or access to
medical care is
required:
N/A
ClosingQuestionsModel.Surger Answers.Condition
Condition:
N/A
ClosingQuestionsModel.Surger Answers.DateOfEvaluation
Date of
evaluation for
this condition:
1/1/2012
ClosingQuestionsModel.Surger Answers.OpeningQuestion
Have ou had
surger in our
lifetime for
which ou have
not seen a
medical
professional in
the past two
ears but for
which ou will
require access
to care for this
specific surgical
condition?
True
ClosingQuestionsModel.Surger Answers.RecommendedFollowUp
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
Follow up
evaluation or
diagnostic
testing is
N/A
17/64
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DiagnosisVerification
:
C
Q
M
.S
A
.R
C
Q
M
.S
A
.R
R
T
N/A
:
W
A
T M
C
N/A
:
C
Q
M
.T
I
A
.C
C
Q
M
.T
I
A
.D
C
:
N/A
D
OE
:
1/1/2012
H
(
)
,
C
Q
M
.T
I
A
.O
Q
T
?
F
C
Q
M
.T
I
A
.R
F
U
N/A
:
C
Q
M
.T
I
A
.R
C
Q
M
.T
I
A
.R
R
T
:
N/A
W
A
T M
C
N/A
:
Dermatolog
ID
I
D
Ans er
Te t
Question Te t
M
.S
D
I L
P
D
24M
(I
P
I
C
.
Y
,
).
D
M
.A
A
.D
OD
D
M
.A
A
.D
OR
D
: 1/1/2012
D
:
1/1/2012
I
(U
D
M
.A
A
.H
M
P
C
,
T
.)
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
18/64
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DiagnosisVerification
Dermatolog Model.AlopeciaAnswers.Medications
Please list an
medications ou
are currentl
taking for this
condition.
Separate
individual
medications with
a comma.
N/A
Dermatolog Model.AlopeciaAnswers.NeedMonitoring
It is
recommended b
m health
professional that
I see a
Dermatologist for
speciali ed
monitoring or
follow up for this
condition.
True
Dermatolog Model.AlopeciaAnswers.NeedMonitoringDescription
Description:
N/A
Dermatolog Model.AlopeciaAnswers.NoS mptoms
This condition is
resolved without
s mptoms for
over a ear, I
have no
restrictions or
limitations due to
this condition and
it requires no
further follow up
True
Dermatolog Model.AlopeciaAnswers.OpeningQuestion
Diagnosis:
Alopecia (Hair
Loss)
True
Please respond to
all of the bullet
points below.
How does
this
condition
affect our
activities of
dail
living/work?
What is
our plan
for
managing
an
s mptoms
while
serving
with the
Peace
Corps?
Dermatolog Model.AlopeciaAnswers.PersonalStatement
Describe
our
N/A
response
to all
treatments
prescribed
for this
condition.
Do ou
have an
concerns
related to
this
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
19/64
1/18/12
DiagnosisVerification
this
condition
that ma
impact on
our abilit
to serve 27
months
with the
Peace
Corps? If
so, please
describe.
Dermatolog Model.C sticAcneAnswers.DateOfDiagnosis
Date of diagnosis: 1/1/2012
Dermatolog Model.C sticAcneAnswers.DateOfResolution
Date of
resolution:
1/1/2012
Dermatolog Model.C sticAcneAnswers.HadEpisodesOfC sticAcne
I have had 2 or
more episodes of
C stic Acne in m
life
True
Dermatolog Model.C sticAcneAnswers.HasMedications
I require oral (b
mouth) or topical
(applied to
affected area)
medication either
dail or as
needed for this
condition
Note: Peace
Corps does not
support the use
of Accutane
(Isotretinoin)
during service
True
Dermatolog Model.C sticAcneAnswers.Medications
Please list an
medications ou
are currentl
taking for this
condition.
Separate
individual
medications with
a comma.
N/A
Dermatolog Model.C sticAcneAnswers.NeedMonitoring
It is
recommended b
m health
professional that
I see a
Dermatologist for
speciali ed
monitoring or
follow up for this
condition.
True
Dermatolog Model.C sticAcneAnswers.NeedMonitoringDescription
Description:
N/A
Dermatolog Model.C sticAcneAnswers.NoS mptoms
This condition is
resolved without
s mptoms for
over a ear, I
have no
restrictions or
limitations due to
this condition and
it requires no
further follow up
True
Dermatolog Model.C sticAcneAnswers.OpeningQuestion
Diagnosis: C stic
Acne
True
Please respond to
all of the bullet
points below.
How does
this
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
condition
20/64
1/18/12
DiagnosisVerification
condition
affect our
activities of
dail
living/work?
What is
our plan
for
managing
an
s mptoms
while
serving
with the
Peace
Corps?
Describe
our
Dermatolog Model.C sticAcneAnswers.PersonalStatement
response
N/A
to all
treatments
prescribed
for this
condition.
Do ou
have an
concerns
related to
this
condition
that ma
impact on
our abilit
to serve 27
months
with the
Peace
Corps? If
so, please
describe.
Dermatolog Model.C sticAcneAnswers.RequireSteroids
I currentl require
steroid injections
OR Accutane
(Isotretinoin) to
manage m acne.
Dermatolog Model.PilonidalC stAnswers.DateOfDiagnosis
Date of diagnosis: 1/1/2012
Dermatolog Model.PilonidalC stAnswers.HadS mptoms
I have/had
s mptoms due to
this condition
True
Dermatolog Model.PilonidalC stAnswers.OpeningQuestion
Diagnosis:
Pilonidal C st
True
Dermatolog Model.UnknownAcneAnswers.DateOfDiagnosis
Date of diagnosis: 1/1/2012
Dermatolog Model.UnknownAcneAnswers.DateOfResolution
Date of
resolution:
1/1/2012
Dermatolog Model.UnknownAcneAnswers.HadEpisodesOfC sticAcne
I have had 2 or
more episodes of
Unknown T pe of
Acne in m life
True
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
I require oral (b
mouth) or topical
(applied to
affected area)
True
21/64
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DiagnosisVerification
Dermatolog Model.UnknownAcneAnswers.HasMedications
affected area)
medication either
dail or as
needed for this
condition
Note: Peace
Corps does not
support the use
of Accutane
(Isotretinoin)
during service
True
Dermatolog Model.UnknownAcneAnswers.Medications
Please list an
medications ou
are currentl
taking for this
condition.
Separate
individual
medications with
a comma.
N/A
Dermatolog Model.UnknownAcneAnswers.NeedMonitoring
It is
recommended b
m health
professional that
I see a
Dermatologist for
speciali ed
monitoring or
follow up for this
condition.
True
Dermatolog Model.UnknownAcneAnswers.NeedMonitoringDescription Description:
N/A
Dermatolog Model.UnknownAcneAnswers.NoS mptoms
This condition is
resolved without
s mptoms for
over a ear, I
have no
restrictions or
limitations due to
this condition and
it requires no
further follow up
True
Dermatolog Model.UnknownAcneAnswers.OpeningQuestion
Diagnosis:
Unknown T pe of
Acne
True
Please respond to
all of the bullet
points below.
How does
this
condition
affect our
activities of
dail
living/work?
What is
our plan
for
managing
an
s mptoms
while
serving
with the
Peace
Corps?
Describe
Dermatolog Model.UnknownAcneAnswers.PersonalStatement
our
N/A
response
to all
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
treatments
22/64
1/18/12
DiagnosisVerification
treatments
prescribed
for this
condition.
Do ou
have an
concerns
related to
this
condition
that ma
impact on
our abilit
to serve 27
months
with the
Peace
Corps? If
so, please
describe.
Dermatolog Model.UnknownAcneAnswers.RequireSteroids
I currentl require
steroid injections
OR Accutane
(Isotretinoin) to
manage m acne.
Dermatolog Model.VulgarisAcneAnswers.DateOfDiagnosis
Date of diagnosis: 1/1/2012
Dermatolog Model.VulgarisAcneAnswers.DateOfResolution
Date of
resolution:
1/1/2012
Dermatolog Model.VulgarisAcneAnswers.HadEpisodesOfC sticAcne
I have had 2 or
more episodes of
Vulgaris Acne in
m life
True
Dermatolog Model.VulgarisAcneAnswers.HasMedications
Dermatolog Model.VulgarisAcneAnswers.Medications
I require oral (b
mouth) or topical
(applied to
affected area)
medication either
dail or as
needed for this
condition
Note: Peace
Corps does not
support the use
of Accutane
(Isotretinoin)
during service
Please list an
medications ou
are currentl
taking for this
condition.
Separate
individual
medications with
a comma.
True
True
N/A
Dermatolog Model.VulgarisAcneAnswers.NeedMonitoring
It is
recommended b
m health
professional that
I see a
Dermatologist for
speciali ed
monitoring or
follow up for this
condition.
True
Dermatolog Model.VulgarisAcneAnswers.NeedMonitoringDescription
Description:
N/A
This condition is
resolved without
s mptoms for
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
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DiagnosisVerification
Dermatolog Model.VulgarisAcneAnswers.NoS mptoms
Dermatolog Model.VulgarisAcneAnswers.OpeningQuestion
s mptoms for
over a ear, I
have no
restrictions or
limitations due to
this condition and
it requires no
further follow up
Diagnosis:
Vulgaris Acne
True
True
Please respond to
all of the bullet
points below.
How does
this
condition
affect our
activities of
dail
living/work?
What is
our plan
for
managing
an
s mptoms
while
serving
with the
Peace
Corps?
Describe
Dermatolog Model.VulgarisAcneAnswers.PersonalStatement
our
N/A
response
to all
treatments
prescribed
for this
condition.
Do ou
have an
concerns
related to
this
condition
that ma
impact on
our abilit
to serve 27
months
with the
Peace
Corps? If
so, please
describe.
Dermatolog Model.VulgarisAcneAnswers.RequireSteroids
I currentl require
steroid injections
OR Accutane
(Isotretinoin) to
manage m acne.
True
Dermatolog Model.AlopeciaAnswers.S mptoms.AreAn Ongoing
True
Dermatolog Model.C sticAcneAnswers.S mptoms.AreAn Ongoing
True
Dermatolog Model.UnknownAcneAnswers.S mptoms.AreAn Ongoing
True
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
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DiagnosisVerification
Dermatolog Model.UnknownAcneAnswers.S mptoms.AreAn Ongoing
True
Dermatolog Model.VulgarisAcneAnswers.S mptoms.AreAn Ongoing
True
Ear, Nose, Throat
Ans er
Te t
ID
Question Te t
ENTModel.DeafUseSignLanguage
I am deaf and use
American Sign
Language as m
True
primar form of
communication
Please respond to
all of the bullet
points below.
How does
this
condition
affect our
activities of
dail
living/work?
What is
our plan
for
managing
an
s mptoms
while
serving
with the
Peace
Corps?
Describe
our
ENTModel.DeafUseSignPersonalStmt
response
N/A
to all
treatments
prescribed
for this
condition.
Do ou
have an
concerns
related to
this
condition
that ma
impact on
our abilit
to serve 27
months
with the
Peace
Corps? If
so, please
describe.
I am deaf and use
ENTModel.DeafUseSpeech
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
speech and
residual hearing
as m primar
form of
True
25/64
1/18/12
DiagnosisVerification
communication
Please respond to
all of the bullet
points below.
How does
this
condition
affect our
activities of
dail
living/work?
What is
our plan
for
managing
an
s mptoms
while
serving
with the
Peace
Corps?
Describe
ENTModel.DeafUseSpeechPersonalStmt
our
response
N/A
to all
treatments
prescribed
for this
condition.
Do ou
have an
concerns
related to
this
condition
that ma
impact on
our abilit
to serve 27
months
with the
Peace
Corps? If
so, please
describe.
ENTModel.NoDifficult Hearing
I have no difficult
hearing
True
ENTModel.SeenDoctorInLast24Months
In the past two
ears I have seen
a Primar Care
Ph sician or Ear,
Nose, and Throat
Specialist for an
Ear, Nose, and
Throat condition.
(If ou are
unsure, click here
for a list of
conditions).
Yes
ENTModel.CholesteatomaAnswers.CholesteatomaIncidence
I have had a
single incidence of True
a Cholesteatoma
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
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DiagnosisVerification
ENTModel.CholesteatomaAnswers.DateOfDiagnosis
Date of diagnosis: 1/1/2012
ENTModel.CholesteatomaAnswers.DateOfResolution
Date of
resolution:
1/1/2012
ENTModel.CholesteatomaAnswers.EarsAffected
Ear(s) affected
Both
ENTModel.CholesteatomaAnswers.HadSurger Past2Yrs
I had surger in
the past 2 ears
due to this
condition
True
ENTModel.CholesteatomaAnswers.HadS mptoms
I have/had
s mptoms due to
this condition
True
ENTModel.CholesteatomaAnswers.ListDates
List Dates
N/A
ENTModel.CholesteatomaAnswers.MoreThanOnceCondition
I have had this
condition more
than once in m
lifetime
True
ENTModel.CholesteatomaAnswers.NeedFutureSurger
I am told I need,
or ma need,
surger in the
future due to this
condition
True
ENTModel.CholesteatomaAnswers.NeedFutureSurger Desc
Description:
N/A
ENTModel.CholesteatomaAnswers.NeedMonitoring
It is
recommended b
m health
professional that
I see an Ear,
Nose and Throat
ph sician for
speciali ed
monitoring or
follow up for this
condition
True
ENTModel.CholesteatomaAnswers.NeedMonitoringDesc
Description:
N/A
ENTModel.CholesteatomaAnswers.NoS mptoms
This condition is
resolved without
s mptoms for
over a ear, I
have no
restrictions or
limitations due to
this condition and
it requires no
further follow up
True
ENTModel.CholesteatomaAnswers.OpeningQuestion
Diagnosis:
Cholesteatoma
(usuall a benign
tumor of the ear)
True
Please respond to
all of the bullet
points below.
How does
this
condition
affect our
activities of
dail
living/work?
What is
our plan
for
managing
an
s mptoms
while
serving
with the
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
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DiagnosisVerification
Peace
Co p ?
De c ibe
o
ENTModel.Chole
ea omaAn
e
.Pe
onalS a emen
e pon e
N/A
o all
ea men
p e c ibed
fo
hi
condi ion.
Do o
ha e an
conce n
ela ed o
hi
condi ion
ha ma
impac on
o
abili
o e
e 27
mon h
i h he
Peace
Co p ? If
o, plea e
de c ibe.
ENTModel.DeafU eSignLang age.da e
Da e of diagno i : 1/1/2012
ENTModel.DeafU eSpeech.da e
Da e of diagno i : 1/1/2012
ENTModel.Ha dToHea Condi ion .Ea
Affec ed
Ea ( ) affec ed
Bo h
I ha e had
diagno ic e ing
( ch a a
hea ing e ) in
d e o hi
condi ion
T
e
ENTModel.Ha dToHea Condi ion .Ha dToHea
I am ha d of
hea ing and I
e
peech a m
p ima fo m of
comm nica ion
T
e
ENTModel.Ha dToHea Condi ion .Hea ingAidDe ail
Li
pe, da e of
p cha e,
man fac e and
model
n mbe (p o ide if
kno n)
N/A
ENTModel.Ha dToHea Condi ion .Hea ingAidReplacemen
The hea ing aid
ma need o be
eplaced in he
ne 3 ea
T
e
ENTModel.Ha dToHea Condi ion .Hea ingLo
The ca e of he
hea ing lo
i
kno n
T
e
ENTModel.Ha dToHea Condi ion .HadDiagno
icTe
Ca
ing
e
Plea e e pond o
all of he b lle
poin belo .
Ho
doe
hi
condi ion
affec
o
ac i i ie of
dail
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
28/64
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DiagnosisVerification
i i g/
?
Wha i
a
f
a agi g
a
hi e
e
i g
i h he
Peace
C
?
De c ibe
ENTM de .Ha dT Hea C
di i
.Hea i gL
Pe
aSa e e
e
N/A
e
a
ea
e
e c ibed
f
hi
c
di i
.
D
ha e a
c
ce
e a ed
hi
c
di i
ha
i
a
ac
abi i
e
e 27
h
i h he
Peace
C
? If
,
ea e
de c ibe.
ENTM de .Ha dT Hea C
di i
.Li Ca
e
ENTM de .Ha dT Hea C
di i
.Re
ENTM de .Ha dT Hea C
di i
.SeeENTDe c
i eHea i gAid
Li :
N/A
I e i e he
e
f a hea i g aid
T
De c ibe
N/A
e
I i
ec
ENTM de .Ha dT Hea C
di i
.SeeENTPh
icia
ENTM de .Me ie e Di ea eA
e
.Da eOfDiag
ENTM de .Me ie e Di ea eA
e
.HadS
ENTM de .Me ie e Di ea eA
e
.HadS
ENTM de .Me ie e Di ea eA
e
ENTM de .Me ie e Di ea eA
e
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
e ded b
hea h
fe i a ha
I ee a Ea ,
N e a d Th a
h icia f
ecia i ed
i i g
f
f
hi
c di i .
ge
i
Pa
2Y
Da e
f diag
I had
hi c
ge
di i
T
e
i : 1/1/2012
f
T
e
I ha e/had
d e
hi c di i
T
e
.Hea i gL
Ia c e
e e ie ci g
hea i g
d e
hi c di i
T
e
.Li Da e
Li
N/A
Da e
29/64
1/18/12
DiagnosisVerification
ENTModel.MenieresDiseaseAnswers.ListDates
List Dates
N/A
ENTModel.MenieresDiseaseAnswers.Medications
Please list any
medications you
are currently
taking for this
condition.
Separate
individual
medications with
a comma.
N/A
ENTModel.MenieresDiseaseAnswers.MoreThanOnceCondition
I have had this
condition more
than once in my
lifetime
True
ENTModel.MenieresDiseaseAnswers.NeedFutureSurgery
I am told I need,
or may need,
surgery in the
future due to this
condition
True
ENTModel.MenieresDiseaseAnswers.NeedFutureSurgeryDesc
Description:
N/A
ENTModel.MenieresDiseaseAnswers.NeedMonitoring
It is
recommended by
my health
professional that
I see an Ear,
Nose and Throat
physician for
specialized
monitoring or
follow up for this
condition
True
ENTModel.MenieresDiseaseAnswers.OpeningQuestion
Diagnosis:
Meniere s Disease
(affects balance
and hearing)
True
ENTModel.MenieresDiseaseAnswers.RequireMedication
I require
medication either
daily or as
needed for this
condition
True
ENTModel.CholesteatomaAnswers.Symptoms.AreAnyOngoing
True
ENTModel.HardToHearConditions.HardToHear.date
Date of diagnosis: 1/1/2012
ENTModel.HardToHearConditions.HearingAidReplacement.date
Date of expected
future
replacement
ENTModel.MenieresDiseaseAnswers.Symptoms.AreAnyOngoing
1/1/2012
True
Endocrinolog
ID
Question Te t
EndocrinologyModel.AddisonsDisease
Addison s Disease
(hypo adrenal
glands and/or
reduced
corticosteroid
levels)
EndocrinologyModel.CongenitalAdrenalHyperplasia
Congenital
Adrenal
Hyperplasia
EndocrinologyModel.CushingsDisease
Cushing s Disease
(hyper adrenal
glands and/or
elevated
corticosteroid
levels)
EndocrinologyModel.DiabetesType1
Diabetes Type 1
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
In the past two
years I have seen
a primary care
physician or
30/64
1/18/12
DiagnosisVerification
Endoc inolog Model.SeenDoc o InLa
ph ician o
endoc inologi o
o he peciali
fo a condi ion of
he Endoc ine
S
em (diabe e
o condi ion of
he pi i a ,
h oid,
pa a h oid and
ad enal gland fo
e ample). If o
a e n
e, click
he e fo a li of
Endoc ine
condi ion )
24Mon h
Endoc inolog Model.Addi on Di ea e.da e
Da e of diagno i :
Endoc inolog Model.Addi on Di ea e.Doc o La
When a he
la
ime o
a
a Heal h Ca e
p o ide fo hi
condi ion:
SeenDa e
Endoc inolog Model.Congeni alAd enalH pe pla ia.da e
Da e of diagno i :
Endoc inolog Model.Congeni alAd enalH pe pla ia.Doc o La
When a he
la
ime o
a
a Heal h Ca e
p o ide fo hi
condi ion:
Endoc inolog Model.C
SeenDa e
hing Di ea e.da e
Da e of diagno i :
When
Endoc inolog Model.C
hing Di ea e.Doc o La
a
he
la
ime o
a
a Heal h Ca e
p o ide fo hi
condi ion:
SeenDa e
Endoc inolog Model.Diabe e Melli
T pe2An
e
.ChangedMedica ion
M doc o
changed m
medica ion i hin
he pa 3
mon h (ei he
opped o
a ed a
medica ion o
changed he
do age of a
c en
medica ion)
Endoc inolog Model.Diabe e Melli
T pe2An
e
.Da eOfDiagno i
Da e of diagno i :
Endoc inolog Model.Diabe e Melli
T pe2An
e
.Da eOfRe ol
ion
Da e of
e ol ion:
InPa
I ha e had blood
e
o o he
diagno ic e ing
in he pa 6
mon h d e o
hi condi ion
Endoc inolog Model.Diabe e Melli
T pe2An
e
.HadBloodTe
Endoc inolog Model.Diabe e Melli
T pe2An
e
.HadNe
Endoc inolog Model.Diabe e Melli
T pe2An
e
.HadS
Endoc inolog Model.Diabe e Melli
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
T pe2An
e
6Mon h
opa h
ge
.HemoglobinA1CLabTe
I ha e
ne opa h (lo
of en a ion o
ne e pain) d e
o hi condi ion
I had
ge d e
o hi condi ion
in he pa 2
ea
I ha e had a
Hemoglobin A1C
lab e in he la
3 mon h
I ha e had one o
mo e epi ode of
lo blood
ga
ha incl ded a
change in
con cio ne
31/64
1/18/12
DiagnosisVerification
E
M
.D
M
T
2A
.L
B
S
(
)
I
E
M
.D
M
T
2A
.M
B D
A
E
I
E
M
.D
M
T
2A
.M
N
I
,
,
S
P
E
M
.D
M
T
2A
.M
.
S
.
I
E
M
.D
M
T
2A
.N
F
I
E
U
.
T
,I
E
M
.D
M
T
2A
.N S
D
D
T
E
M
.D
M
T
2A
.O
Q
2 (I
T
:
M
1,
)
I
E
M
.D
M
T
2A
.O
B
S
I
(
,
)
P
.
H
/
?
W
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
32/64
1/18/12
DiagnosisVerification
for
managing
an
s mptoms
while
serving
with the
Peace
Corps?
Describe
Endocrinolog Model.DiabetesMellitusT pe2Answers.PersonalStatement
our
response
to all
treatments
prescribed
for this
condition.
Do ou
have an
concerns
related to
this
condition
that ma
impact on
our abilit
to serve 27
months
with the
Peace
Corps? If
so, please
describe.
Endocrinolog Model.DiabetesMellitusT pe2Answers.RequireMedication
I require oral (b
mouth) or
Injectable(b a
shot) medication
either dail or as
needed for this
condition
Endocrinolog Model.DiabetesMellitusT pe2Answers.SeenInEmergenc Room
I have been to an
emergenc room
or urgent care
center or have
been hospitali ed
in the past 2
ears because of
this condition
Endocrinolog Model.DiabetesMellitusT pe2Answers.SpecialDiet
I follow a special
diet due to having
this condition
I am unable to
Endocrinolog Model.DiabetesMellitusT pe2Answers.UnableToCheckOldBloodSugars check m own
blood sugars
Endocrinolog Model.DiabetesT pe1.date
Date of diagnosis:
Endocrinolog Model.DiabetesT pe1.DoctorLastSeenDate
When was the
last time ou saw
a Health Care
provider for this
condition:
Endocrinolog Model.H pogl cemiaAnswers.DateOfDiagnosis
Date of diagnosis:
Endocrinolog Model.H pogl cemiaAnswers.HadBloodTestsInPast3Months
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
I have had blood
tests due to this
condition in the
33/64
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DiagnosisVerification
condition in the
past 3 months
EndocrinologyModel.HypoglycemiaAnswers.HadConditionMoreThanOnce
I have had this
condition more
than once
EndocrinologyModel.HypoglycemiaAnswers.HadSymptoms
I have/had
symptoms due to
this condition
EndocrinologyModel.HypoglycemiaAnswers.NeedFollowUp
It is
recommended by
my health
professional that
I see an
Endocrinologist
for specialized
monitoring or
follow up for this
condition.
EndocrinologyModel.HypoglycemiaAnswers.NoSymptoms
This condition is
resolved without
symptoms for
over a year, I
have no
restrictions or
limitations due to
this condition and
it requires no
further follow up
EndocrinologyModel.HypoglycemiaAnswers.OpeningQuestion
Diagnosis:
Hypoglycemia
EndocrinologyModel.HypoglycemiaAnswers.SeenInEmergencyRoom
I have been to an
emergency room
or urgent care
center or have
been hospitalized
in the past 2
years because of
this condition
List medication
EndocrinologyModel.DiabetesMellitusType2Answers.ChangedMedication.Desc
and describe
reason for
change:
EndocrinologyModel.DiabetesMellitusType2Answers.HadNeuropathy.Desc
Describe:
EndocrinologyModel.DiabetesMellitusType2Answers.MayNeedSurgery.Desc
Describe:
EndocrinologyModel.DiabetesMellitusType2Answers.NeedFollowUp.Describe
Describe:
EndocrinologyModel.DiabetesMellitusType2Answers.OtherBodySystemsInvolved.
Desc
Describe:
EndocrinologyModel.DiabetesMellitusType2Answers.SpecialDiet.Desc
Describe:
EndocrinologyModel.HypoglycemiaAnswers.HadConditionMoreThanOnce.List
List:
EndocrinologyModel.HypoglycemiaAnswers.NeedFollowUp.Describe
Describe:
EndocrinologyModel.HypoglycemiaAnswers.Symptoms.AreAnyOngoing
Gastroenterolog
ID
Question Te t
Ans er
Te t
GastroenterologyModel.AbsorptionDisorder
Any absorption
disorder, such as
Crohn s Disease
or Ulcerative
Colitis
True
GastroenterologyModel.ActiveHepatitisB
Active Hepatitis B
OR I am a
Hepatitis B carrier
True
GastroenterologyModel.Ascites
Ascites
True
GastroenterologyModel.Cirrhosis
Cirrhosis of the
Liver
True
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
34/64
1/18/12
DiagnosisVerification
GastroenterologyModel.Colonoscopy
Colonoscopy
(within 10 years)
True
GastroenterologyModel.CTColongraphy
CT Colongraphy
Virtual
Colonoscopy
(within 5 years)
True
GastroenterologyModel.DNATesting
Stool for DNA
testing (within 1
year)
True
GastroenterologyModel.DoubleContrastBariumEnema
Double Contrast
Barium Enema
(within 5 years)
True
GastroenterologyModel.EsophagealVarices
Esophageal
Varices
True
GastroenterologyModel.FecalImmunochemicalTest
Fecal
Immunochemical
Test (within 1
year)
True
GastroenterologyModel.FecalOccultBloodTest
Fecal Occult Blood
Test x 3 (within 1
year)
True
GastroenterologyModel.FlexibleSigmoidoscopy
Flexible
Sigmoidoscopy
(within 5 years)
True
GastroenterologyModel.GlutenTolerant
I am able to
tolerate gluten in
my diet
No
GastroenterologyModel.HepatitisC
Hepatitis C
True
GastroenterologyModel.LactoseTolerant
I am able to
tolerate lactose in
my diet and do
not avoid dairy
products
No
GastroenterologyModel.NeedsColoRectalScreeningExam
HIDDEN- Does the
canidate need a
colo-rectal
screening exam
Yes
I have not had
any of the listed
GastroenterologyModel.NoColoRectalScreeningWithinDefinedTimeframes tests above within
the defined time
frames
True
GastroenterologyModel.Othersurgicalrepair
I currently have a
Colostomy,
Ileostomy or any
other surgical
repair of the colon
that requires daily
care and
maintenance
True
GastroenterologyModel.SeenDoctorInLast24Months
In the past two
years I have seen
a Primary Care
Physician or
Gastroenterologist
for a Colon,
Yes
Stomach,
Pancreas or Liver
condition (If you
are unsure, click
here for a list of
conditions)
GastroenterologyModel.Under50
I am under 50
years of age
No
GastroenterologyModel.UndergoneBariatricSurgery
I have undergone
Bariatric Surgery
for weight loss
True
GastroenterologyModel.AbsorptionDisorder.DiagnosisDate
Date of diagnosis:
1/1/2012
GastroenterologyModel.ActiveHepatitisB.DiagnosisDate
Date of diagnosis:
1/1/2012
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
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DiagnosisVerification
Ga
e
e
g M de .A ci e .Diag
Ga
e
e
g M de .Ci h
Ga
e
e
g M de .C
i Da e
i .Diag
c
i Da e
.I Ab
Ga
e
e
g M de .CTC
g a h .I Ab
Ga
e
e
g M de .DNATe
i g.I Ab
Ga
e
e
g M de .D
Ga
e
e
g M de .E
b eC
e
e
g M de .Feca I
Ga
e
e
g M de .Feca Occ
e
e
a
E e a.I Ab
che ica Te
B
g M de .F e ib eSig
dTe
id
c
i :
1/1/2012
Da e
f diag
i :
1/1/2012
a
i Da e
.I Ab
.I Ab
.I Ab
T
e
T
e
M e
a
ab
a a d
e i ed f he
f
e i g
T
e
M e
a
ab
a a d
e i ed f he
f
e i g
T
e
Da e
1/1/2012
f
e i g
M e
a
ab
a a d
e i ed f he
f
e i g
a
Ba i
f diag
M e
a
ab
a a d
e i ed f he
a
hagea Va ice .Diag
Ga
Ga
a
Da e
a
a
a
f diag
i :
M e
a
ab
a a d
e i ed f he
f
e i g
T
e
M e
a
ab
a a d
e i ed f he
f
e i g
T
e
M e
a
ab
a a d
e i ed f he
f
e i g
T
e
P ea e e
a
f he b
i
be
e
.
H
d
d e
hi
c
di i
affec
ac i i ie
f
dai
i i g/
?
Wha i
a
f
a agi g
a
hi e
e
i g
ih
he Peace
C
?
De c ibe
Ga
e
e
g M de .G
e T e a
.Pe
aSa e e
e
e
N/A
a
ea
e
e c ibed
f
hi
c
di i
.
D
ha e a
c
ce
e a ed
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
36/64
1/18/12
DiagnosisVerification
hi
c
di i
ha
i
a
ac
abi i
e
e 27
h
ih
he Peace
C
? If
,
ea e
de c ibe.
Ga
e
e
g M de .He a i i A
e
.He a i i A
He a i i A
T
e
Ga
e
e
g M de .He a i i A
e
.He a i i B
He a i i B
T
e
.O e i gQ e
Diag
i :
He a i i
(i f a
a i
f
he i e ) (If
ha e a ead
a
e ed
e i
hi
c di i
i
a
he b d
e d
chec hi b )
T
e
Da e
1/1/2012
Ga
e
e
g M de .He a i i A
e
Ga
e
e
g M de .He a i i C.Diag
i
i Da e
f diag
i :
P ea e e
a
f he b
i
be
e
.
H
d
d e
hi
c
di i
affec
ac i i ie
f
dai
i i g/
?
Wha i
a
f
a agi g
a
hi e
e
i g
ih
he Peace
C
?
De c ibe
Ga
e
e
g M de .Lac
eT e a
.Pe
aSa e e
N/A
e
e
a
ea
e
e c ibed
f
hi
c
di i
.
D
ha e a
c
ce
e a ed
hi
c
di i
ha
i
a
ac
abi i
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
37/64
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DiagnosisVerification
our abilit
to serve 27
months with
the Peace
Corps? If
so, please
describe.
Gastroenterolog Model.UndergoneBariatricSurger .DiagnosisDate
(Date of Suger )
1/1/2012
Gastroenterolog Model.AbsorptionDisorder.HealthCareProvider.Date
When was the
last time ou saw
a Health Care
provider for this
condition?
1/1/2012
Gastroenterolog Model.ActiveHepatitisB.HealthCareProvider.Date
When was the
last time ou saw
a Health Care
provider for this
condition?
1/1/2012
Gastroenterolog Model.Ascites.HealthCareProvider.Date
When was the
last time ou saw
a Health Care
provider for this
condition?
1/1/2012
Gastroenterolog Model.Cirrhosis.HealthCareProvider.Date
When was the
last time ou saw
a Health Care
provider for this
condition?
1/1/2012
Gastroenterolog Model.EsophagealVarices.HealthCareProvider.Date
When was the
last time ou saw
a Health Care
provider for this
condition?
1/1/2012
Gastroenterolog Model.HepatitisAnswers.HepatitisA.DiagnosisDate
Date of diagnosis:
1/1/2012
Gastroenterolog Model.HepatitisAnswers.HepatitisB.DiagnosisDate
Date of diagnosis:
1/1/2012
Gastroenterolog Model.HepatitisC.HealthCareProvider.Date
When was the
last time ou saw
a Health Care
provider for this
condition?
1/1/2012
Gastroenterolog Model.Othersurgicalrepair.HealthCareProvider.Date
When was the
last time ou saw
a Health Care
provider for this
condition?
1/1/2012
Gastroenterolog Model.UndergoneBariatricSurger .HealthCareProvider.
Date
When was the
last time ou saw
a Health Care
provider for this
condition?
1/1/2012
G naecolog
ID
Question Te t
Ans er Te t
G neModel.IsMale
I am male
Yes
Hematolog
ID
Question Te t
Hematolog Model.AgnogenicM eloidMetaplasia
Agnogenic
M eloid
Metaplasia
Hematolog Model.EssentialThromboc themia
Essential
(Primar )
Thromboc them
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
A G6PD deficie
(if ou do not
38/64
1/18/12
DiagnosisVerification
Hema olog Model.HadG6PDDeficienc
(if o do no
kno , do no
check hi bo )
Hema olog Model.Hemoch oma o i
Hemoch oma o
Hema olog Model.Hemophilia
Hemophilia
Hema olog Model.L mphoma
L mphoma
(Hodgkin Di ea
Non-Hodgkin
L mphoma ,
M l iple M elom
Hema olog Model.M elofib o i
M elofib o i
Hema olog Model.M SpleenRemo ed
M pleen ha
been emo ed
Plea e e pon
all of he b lle
poin belo .
Ho
doe
hi
condi ion
affec
o
ac i i ie
dail
li ing/ o
Wha i
o
pla
fo
managin
an
mp om
hile
e
ing
i h he
Peace
Co p ?
De c ibe
Hema olog Model.Pe
onalS a emen
o
e pon
o all
ea me
p e c ib
fo
hi
condi ion
Do o
ha e an
conce n
ela ed
hi
condi ion
ha ma
impac o
o
abi
o e
e
mon h
i h he
Peace
Co p ? I
o, plea
de c ibe
Hema olog Model.Pol c hemiaVe a
Pol c hemia V
In he pa
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
39/64
1/18/12
DiagnosisVerification
Hematolog Model.SeenDoctorInLast24Months
ears I have s
a Primar Care
Ph sician or
Hematologist f
a blood conditi
(If ou are
unsure, click he
for a list of
conditions)
Hematolog Model.SickleCellDisease
Sickle Cell,
Thalassemia,
Hemoglobin C
SC DISEASE NO
TRAIT
Hematolog Model.AgnogenicM eloidMetaplasia.DiagnosisDate
Date of diagno
Hematolog Model.AgnogenicM eloidMetaplasia.ProviderLastSeenDate
When was the
last time ou s
a Health Care
provider for th
condition?
Hematolog Model.AutoImmuneHemol ticAnemiaAnswers.DateOfDiagnosis
Date of diagno
Hematolog Model.AutoImmuneHemol ticAnemiaAnswers.DateOfResolution
Date of
resolution:
Hematolog Model.AutoImmuneHemol ticAnemiaAnswers.DoctorChangedMedication
M doctor
changed m
medication in t
past 3 months
(either stoppe
started a
medication or
changed the
dosage of a
current
medication)
I have had blo
tests or other
diagnostic test
Hematolog Model.AutoImmuneHemol ticAnemiaAnswers.HadDiagnositicTestingInPast6Months
in the past 6
months due to
this condition
Hematolog Model.AutoImmuneHemol ticAnemiaAnswers.HadS mptoms
I have/had
s mptoms due
this condition
Hematolog Model.AutoImmuneHemol ticAnemiaAnswers.Medications
Please list an
medications o
are currentl
taking for this
condition.
Separate
individual
medications w
a comma.
It is
recommended
m health
professional th
Hematolog Model.AutoImmuneHemol ticAnemiaAnswers.NeedMonitoring
I see a
Hematologist f
speciali ed
monitoring or
follow up for th
condition.
Hematolog Model.AutoImmuneHemol ticAnemiaAnswers.NeedMonitoringDesc
Description:
Hematolog Model.AutoImmuneHemol ticAnemiaAnswers.NoS mptoms
This condition
resolved witho
s mptoms for
over a ear, I
have no
restrictions or
limitations due
this condition a
it requires no
further follow u
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
Diagnosis:
40/64
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DiagnosisVerification
Hematolog Model.AutoImmuneHemol ticAnemiaAnswers.OpeningQuestion
Diagnosis:
Immune Hemo
Anemia
Please respon
all of the bullet
points below.
How doe
this
condition
affect o
activities
dail
living/wo
What is
our pla
for
managin
an
s mptom
while
serving
with the
Peace
Corps?
Describe
Hematolog Model.AutoImmuneHemol ticAnemiaAnswers.PersonalStatement
our
respons
to all
treatme
prescrib
for this
condition
Do ou
have an
concerns
related t
this
condition
that ma
impact o
our abi
to serve
months
with the
Peace
Corps? I
so, plea
describe
Hematolog Model.AutoImmuneHemol ticAnemiaAnswers.RequireMedication
I require oral (
mouth) or
injectable (sho
medication eith
dail or as
needed for this
condition
Hematolog Model.AutoImmuneHemol ticAnemiaAnswers.RequireOngoingTreatment
I currentl requ
ongoing medic
treatment for t
condition
(including
transfusions)
I have been to
emergenc roo
or urgent care
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
41/64
1/18/12
DiagnosisVerification
Hematolog Model.AutoImmuneHemol ticAnemiaAnswers.SeenInEmergenc Room
or urgent care
center or have
been hospitali
in the past 2
ears because
this condition
Hematolog Model.EssentialThromboc themia.DiagnosisDate
Date of diagno
Hematolog Model.EssentialThromboc themia.ProviderLastSeenDate
When was the
last time ou s
a Health Care
provider for th
condition?
Hematolog Model.Hemochromatosis.DiagnosisDate
Date of diagno
Hematolog Model.Hemochromatosis.ProviderLastSeenDate
When was the
last time ou s
a Health Care
provider for th
condition?
Hematolog Model.Hemophilia.DiagnosisDate
Date of diagno
Hematolog Model.Hemophilia.ProviderLastSeenDate
Hematolog Model.Hereditar Hemol ticAnemiaAnswers.DateOfDiagnosis
When was the
last time ou s
a Health Care
provider for th
condition?
Date of diagno
Hematolog Model.Hereditar Hemol ticAnemiaAnswers.HadS mptoms
I have/had
s mptoms due
this condition
Hematolog Model.Hereditar Hemol ticAnemiaAnswers.OpeningQuestion
Diagnosis:
Hereditar
Hemol tic Anem
Hematolog Model.L mphoma.DiagnosisDate
Date of diagno
Hematolog Model.L mphoma.ProviderLastSeenDate
When was the
last time ou s
a Health Care
provider for th
condition?
Hematolog Model.M elofibrosis.DiagnosisDate
Date of diagno
Hematolog Model.M elofibrosis.ProviderLastSeenDate
When was the
last time ou s
a Health Care
provider for th
condition?
Hematolog Model.M SpleenRemoved.Date
Date:
Hematolog Model.M SpleenRemoved.Reason
Reason for
removal
Hematolog Model.Pol c themiaVera.DiagnosisDate
Date of diagno
Hematolog Model.Pol c themiaVera.ProviderLastSeenDate
When was the
last time ou s
a Health Care
provider for th
condition?
Hematolog Model.SickleCellDisease.DiagnosisDate
Date of diagno
Hematolog Model.SickleCellDisease.ProviderLastSeenDate
When was the
last time ou s
a Health Care
provider for th
condition?
Hematolog Model.AutoImmuneHemol ticAnemiaAnswers.Medication.ChangeReason
List medication
and describe
reason for
change:
Hematolog Model.AutoImmuneHemol ticAnemiaAnswers.RequireOngoingTreatment.
Description
Description:
Hematolog Model.AutoImmuneHemol ticAnemiaAnswers.S mptoms.AreAn Ongoing
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
42/64
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DiagnosisVerification
HIPAA Signature
ID
Sig a
eM de .DOB
Sig a
eM de .I Add e
Sig a
eM de .Sig a
Sig a
eM de .Ti eOfSig a
OfSig e
e
Question Te t
Ans er Te t
DOB
1/1/1970
I Add e
Sig a
e
OfSig e
e
Ti eOfSig a
172.27.223.92
E i abe h Keh e
e
1/18/2012
Infectious Disease
ID
Question Te t
Ans er
Te t
I fec M de .He a i i C
He a a i C.
T
e
I fec M de .HIV
H
I
Vi
T
e
I fec M de .PPDN
I ha e had a
i i e PPD a d
ha e
bee
ea ed f
T be c
i .
T
e
I fec M de .PPDT ea ed
I ha e had a
i i e PPD a d
c
e ed a f
c
e f
edica i
f
a e
T be c
i .
T
e
I fec M de .See D c
I the past t o
ears I ha e
ee a P i a
Ca e Ph icia
I fec i
Di ea e S ecia i
f a I fec i
Di ea e (If
'e
e, c ic he e
f a i
f
c di i
)
Ye
.He a i i A
He a i i A
T
e
T
e
T ea ed
I La
I fec M de .He a i i A
e
24M
h
a
deficie c
(HIV).
I fec M de .He a i i A
e
.He a i i B
He a i i B
(Refe
he
di ea e a d NOT
i
i a i
He B e ie )
I fec M de .He a i i A
e
.He a i i c
He a i i C
T
e
I fec M de .He a i i A
e
.He a i i U
Id '
ha
i d f He a i i I
had
T
e
.O e i gQ e
Diag
i :
He a i i
(i f a
a i
f
he i e )
(If
ha e
a ead a
e ed
e i
hi
c di i
i
a
he b d
e ,d
chec hi b )
T
e
I fec M de .He a i i A
e
i
I fec M de .He a i i C.Da e
Da e
I fec M de .He a i i C.P
Whe
a he
a
i e
a
a Hea h Ca e
ide f
hi
c di i ?
I fec M de .HIV.Da e
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
ide La
See Da e
Da e
f diag
f diag
i : 1/1/2012
1/1/2012
i : 1/1/2012
43/64
1/18/12
DiagnosisVerification
InfectModel.HIV.ProviderLastSeenDate
InfectModel.L meDiseaseAnswers.ConditionResolved
When was the
last time ou saw
a Health Care
provider for this
condition?
This condition is
resolved without
s mptoms for
over a ear, I
have no
restrictions or
limitations due to
this condition and
it requires no
further follow up
1/1/2012
True
InfectModel.L meDiseaseAnswers.DiagnosticTest
I have had blood
tests or other
diagnostic test
(such as
Ultrasound) in the
past si months
due to this
condition.
True
InfectModel.L meDiseaseAnswers.HasMedications
I require oral (b
mouth) or inhaled
medication either
dail or as
needed for this
condition
True
InfectModel.L meDiseaseAnswers.HasS mptoms
I have/had
s mptoms due to
this condition.
True
InfectModel.L meDiseaseAnswers.Medications
Please list an
medications ou
are currentl
taking for this
condition.
Separate
individual
medications with
a comma.
N/A
InfectModel.L meDiseaseAnswers.OpeningQuestion
Diagnosis: L me
Disease
True
InfectModel.L meDiseaseAnswers.OtherS stemsInvolvement
I have other bod
s stem(s)
involvement due
to this condition
(such as joint
pain)
True
Please respond to
all of the bullet
points below.
How does
this
condition
affect our
activities of
dail
living/work?
What is
our plan
for
managing
an
s mptoms
while
serving
with the
Peace
Corps?
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
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1/18/12
DiagnosisVerification
De c ibe
I fec M de .L
eDi ea eA
e
.Pe
aSa e e
N/A
e
e
a
ea
e
e c ibed
f
hi
c
di i
.
D
ha e a
c
ce
e a ed
hi
c
di i
ha
i
a
ac
abi i
e
e 27
h
i h he
Peace
C
? If
,
ea e
de c ibe.
I i
ec
I fec M de .L
eDi ea eA
I fec M de .PPDN
e
.S ecia i F
U Re
i ed
e ded b
hea h
fe i a ha
I ee a h icia
f
ecia i ed
i i g
f
d e
hi c di i
T
e
T ea ed.da e
Da e
1/1/2012
I fec M de .PPDN
T ea ed.P
Whe
a he
a
i e
a
a Hea h Ca e
ide f
hi
c di i ?
1/1/2012
I fec M de .PPDN
T ea ed. ea
Rea
ea
N/A
ide La
I fec M de .PPDT ea ed.da eMedica i
I fec M de .PPDT ea ed.P
ide La
I fec M de .STDA
e
.Cha c
I fec M de .STDA
e
.Ch a
I fec M de .STDA
e
.C
I fec M de .STDA
e
.G
I fec M de .STDA
e
.He
C
id
dia
d
1/1/2012
Whe
a he
a
i e
a
a Hea h Ca e
ide f
hi
c di i ?
1/1/2012
Cha c
id
T
e
dia
Ch a
T
e
a
T
e
hea
T
e
T
e
Diag
i :A
Se a
Ta
i ed
Di ea e f
hich
ha e
gh
edica a e i
i he a
ea .
T
e
S
T
e
C
hea
G
e
.O e i gQ e
I fec M de .STDA
e
.S
gi e
e
Da e edica i
c
e ed
a
d
Ge i a He
Si
e
e
hi i
e e
See Da e
I fec M de .STDA
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
See Da e
i
hi i
e
45/64
1/18/12
DiagnosisVerification
InfectModel.STDAnswers.Trichomoniasis
Trichomoniasis
True
InfectModel.HepatitisAnswers.HepatitisA.date
Date
1/1/2012
InfectModel.HepatitisAnswers.HepatitisB.date
Date
1/1/2012
InfectModel.HepatitisAnswers.HepatitisC.date
Date
1/1/2012
InfectModel.L meDiseaseAnswers.ConditionResolved.date
Date of resolution
1/1/2012
InfectModel.L meDiseaseAnswers.L meDisease.date
Date
1/1/2012
InfectModel.L meDiseaseAnswers.SpecialistFollowUpRequired.
Describe
description
N/A
InfectModel.L meDiseaseAnswers.S mptoms.AreAn Ongoing
True
InfectModel.STDAnswers.Chancroid.date
Date
1/1/2012
InfectModel.STDAnswers.Chlam dia.date
Date
1/1/2012
InfectModel.STDAnswers.Cond loma.date
Date
1/1/2012
InfectModel.STDAnswers.Gonorrhea.date
Date
1/1/2012
InfectModel.STDAnswers.Herpes.date
Date
1/1/2012
InfectModel.STDAnswers.S philis.date
Date
1/1/2012
InfectModel.STDAnswers.Trichomoniasis.date
Date
1/1/2012
Neurolog
ID
Question Te t
Ans er
Te t
NeuroModel.Als.OpeningQuestion
Am otrophic
Lateral Sclerosis
(ALS)
True
NeuroModel.An M opath .List
List
N/A
NeuroModel.An M opath .OpeningQuestion
An M opath (a
neuromuscular
disorder) not
previuosl listed
True
NeuroModel.BellPals Answers.BloodTest
I have had blood
tests due to this
condition in the
past three
months
True
NeuroModel.BellPals Answers.ConditionResolved
This condition is
resolved without
s mptoms for at
least three
months, I have
no restrictions or
limitations due to
this condition and
it requires no
further follow up
True
NeuroModel.BellPals Answers.DateOfDiagnosis
Date of diagnosis: 1/1/2012
NeuroModel.BellPals Answers.HasMedications
I require oral (b
mouth)
medication either
dail or as
needed for this
condition
True
NeuroModel.BellPals Answers.HasS mptoms
I have/had
s mptoms due to
this condition.
True
NeuroModel.BellPals Answers.Medications
Please list an
medications ou
are currentl
taking for this
condition.
Separate
individual
medications with
a comma.
N/A
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
46/64
1/18/12
DiagnosisVerification
NeuroModel.BellPals Answers.MonitoringOrFollowupRecommended
It is
recommended b
m health
professional that
I see a
Neurologist for
speciali ed
monitoring or
follow up for this
condition
True
NeuroModel.BellPals Answers.OpeningQuestion
Diagnosis: Bell's
Pals
True
Please respond to
all of the bullet
points below.
How does
this
condition
affect our
activities of
dail
living/work?
What is
our plan
for
managing
an
s mptoms
while
serving
with the
Peace
Corps?
Describe
our
NeuroModel.BellPals Answers.PersonalStatement
response
N/A
to all
treatments
prescribed
for this
condition.
Do ou
have an
concerns
related to
this
condition
that ma
impact on
our abilit
to serve 27
months
with the
Peace
Corps? If
so, please
describe.
NeuroModel.CerebralPals .OpeningQuestion
Cerebral Pals
(CP)
True
NeuroModel.CerebralVascularAccident.OpeningQuestion
Cerebral Vascular
Accident (CVA)
True
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
47/64
1/18/12
DiagnosisVerification
Ne
M de .M .O e i gQ e
Ne
M de .M
Ne
M de .M a
Ne
M de .Pa
Ne
M de .Sei
Ne
i
c a D
h .O e i gQ e
he ia.O e i gQ e
i
.O e i gQ e
M de .Sei
i
i
M i e Sc e
i
(MS)
M c a
D
h (MD)
T
e
T
e
M a
T
e
T
e
Pa i
Di ea e
i
'
e.Li
Li
N/A
e.O e i gQ e
Sei
e di
de
( he ha a
ei
e a a bab
ca ed b high
fe e )
T
e
S ee A ea ha
e ie
a
e i e i he
e
h ee ea
a C-PAP achi e
T
e
T
S
e e'
d
e
T
e
ge a d
ace e
fa
Ve
ic a Sh
T
e
i
Ne
M de .S ee A
Ne
M de .T
Ne
M de .Ve
Ne
M de .A .diag
Ne
M de .A .M
hYea .Da e
Ne
M de .A
M
a h .diag
Ne
M de .A
M
a h .M
Ne
M de .Be Pa
A
e
.C
di i
Ne
M de .Be Pa
de c i i
A
e
.M
i
Ne
M de .Be Pa
A
e
.S
Ne
M de .Ce eb a Pa
.diag
Ne
M de .Ce eb a Pa
.M
Ne
M de .Ce eb a Va c a Accide
.diag
Ne
M de .Ce eb a Va c a Accide
.M
Ne
M de .M .diag
Ne
M de .M .M
Ne
M de .M
c a D
h .diag
Ne
M de .M
c a D
h .M
Ne
M de .M a
he ia.diag
Ne
M de .M a
he ia.M
Ne
M de .Pa
i
.diag
Ne
M de .Pa
i
.M
Ne
M de .Sei
ea.O e i gQ e
e e S
d
i
e.O e i gQ e
ic a Sh
.O e i gQ e
i
S
i
i .Da e
Da e
i .Da e
Da e
hYea .Da e
Re
ed.Da e
i gO F
Rec
.A eA
i : 1/1/2012
e ded.
f diag
i .Da e
M
h/Yea a
ee
h icia f
hi c di i
1/1/2012
Da e
1/1/2012
f e
i
De c ibe
N/A
T
Da e
f diag
i .Da e
hYea .Da e
Da e
f diag
f diag
i .Da e
hYea .Da e
i .Da e
hYea .Da e
i .Da e
hYea .Da e
i .Da e
Da e
f diag
f diag
f diag
f diag
h/Yea
1/1/2012
i : 1/1/2012
M
h/Yea a
ee
h icia f
hi c di i
Da e
1/1/2012
i : 1/1/2012
M
h/Yea a
ee
h icia f
hi c di i
Da e
1/1/2012
i : 1/1/2012
M
h/Yea a
ee
h icia f
hi c di i
Da e
1/1/2012
i : 1/1/2012
M
h/Yea a
ee
h icia f
hi c di i
hYea .Da e
1/1/2012
i : 1/1/2012
M
h/Yea a
ee
h icia f
hi c di i
Da e
e
i : 1/1/2012
M
h/Yea a
ee
h icia f
hi c di i
hYea .Da e
1/1/2012
i : 1/1/2012
O g i g
i .Da e
e.diag
f diag
M
h/Yea a
ee
h icia f
hi c di i
M
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
he ia G a i
1/1/2012
i : 1/1/2012
a
48/64
1/18/12
DiagnosisVerification
NeuroModel.Sei ure.MonthYear.Date
NeuroModel.SleepApnea.diagnosis.Date
seen ph sician for 1/1/2012
this condition
Date of diagnosis: 1/1/2012
NeuroModel.SleepApnea.MonthYear.Date
Month/Year last
seen ph sician for 1/1/2012
this condition
NeuroModel.TourettesS ndrome.diagnosis.Date
Date of diagnosis: 1/1/2012
NeuroModel.TourettesS ndrome.MonthYear.Date
Month/Year last
seen ph sician for 1/1/2012
this condition
NeuroModel.VentricularShunt.diagnosis.Date
Date of Surger
NeuroModel.VentricularShunt.MonthYear.Date
Month/Year last
seen ph sician for 1/1/2012
this condition
1/1/2012
Opening Questions
ID
Question
Te t
Ans er Te t
OpeningQuestionsModel.BMI
BMI
19.9668639053254
OpeningQuestionsModel.CanClimb
I can climb at
least 2 flights
of stairs
carr ing
groceries or
luggage
without
difficult
Yes
OpeningQuestionsModel.CanHoldSquattingPosition
I can hold a
squatting
position for
several
minutes
Yes
OpeningQuestionsModel.CanLift10Pounds
10 pounds
True
OpeningQuestionsModel.CanLift20Pounds
20 pounds
True
OpeningQuestionsModel.CanLift50Pounds
50 pounds
True
OpeningQuestionsModel.CanLiftAtleast10Pounds
I can lift
(check the
highest
weight ou
can lift
without
difficult )
Yes
OpeningQuestionsModel.CannotTolerateAltitude5000ft
I can tolerate
living at an
altitude 5000
feet above
sea level
Yes
OpeningQuestionsModel.CanRideBic cleOnRoughRoads
I can ride a
bic cle on
rough roads
Yes
OpeningQuestionsModel.CanRideVehicleOnRoughRoads
I can tolerate
riding in a
vehicle on
rough roads
Yes
OpeningQuestionsModel.CanTolerateColdLessThan20
Cold < 20
degrees
True
OpeningQuestionsModel.CanTolerateConstantDampness
Constant
Dampness
True
OpeningQuestionsModel.CanTolerateConstantDust
Constant
Dust
True
OpeningQuestionsModel.CanTolerateHeatGrtrThan90
Heat > 90
degrees
True
OpeningQuestionsModel.CanWalk
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
I can walk
distances on
rough or
Yes
49/64
1/18/12
DiagnosisVerification
OpeningQ e
ne en
e ain
I can ide a
bic cle
ion Model.Ca RideBic cle
Ye
ion Model.Diagno edWi hCance
I ha e been
diagno ed
i h cance
(of an
pe)
in m life ime
T
e
ion Model.FilledQ e
Ha e o
e e filled o
a Heal h
Hi o
T
Q e ionnai e
fo he Peace
Co p befo e?
e
Do o ake
an
p e c ip ion
medica ion ?
T
e
ion Model.Ha O e TheCo n e O He balMed
Do o
eg la l ake
an o e he
co n e
medica ion
o he bal
emedie ?
T
e
OpeningQ e
ion Model.Ha eMedica ion ChangedInTheLa
Ha
o
doc o
changed o
medica ion o
ha e o
opped
aking a
medica ion in
he la 6
mon h ?
T
e
OpeningQ e
ion Model.Heigh Inche
Ho
all a e
o ? (Heigh
in inche )
65
OpeningQ e
ion Model.NoLimi a ion OnF nc ionalAbili ie
I ha e no
limi a ion on
m f nc ional
abili ie o
mee m
ac i i ie of
dail li ing.
Ye
OpeningQ e
ion Model.Weigh InPo nd
Ho m ch do
o
eigh?
(Weigh in
po nd )
120
ion Model.Canno Tole a eLi ingCondi ion .De c ip ion
If an of he
abo e bo e
a e checked,
plea e
de c ibe h
o canno
li e in ho e
en i omen :
N/A
OpeningQ e ion Model.Diagno edWi hCance .
Follo Pe iodicall Wi hHCP ofe ional
I follo
p
pe iodicall
i h a heal h
ca e p o ide
in ela ion o
hi cance
diagno i
T
e
OpeningQ e
I ha e
pe iodic
labo a o o
diagno ic
T
e ing d e o
hi Cance
diagno i
e
OpeningQ e
OpeningQ e
OpeningQ e
OpeningQ e
OpeningQ e
ion Model.Ha C
ionnai eEa lie
en Medica ion
6mon h
ion Model.Diagno edWi hCance .Ha ePe iodicTe
ing
Li
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
pe of
50/64
1/18/12
DiagnosisVerification
O e i gQ e i
Ha ePe i dicTe
M de .Diag
i gT e
edWi hCa ce .
e ,
fe e c
O e i gQ e
i
M de .Diag
edWi hCa ce .La
T ea
e
O e i gQ e
i
M de .Diag
edWi hCa ce .Ne
Vi i D eDa e
Da e
T ea
Da e
f La
e
Ne
e ec ed i i
da e d e)
N/A
1/1/2012
1/1/2012
I
O e i gQ e i
M de .Diag
N L ge See HCP
ide
edWi hCa ce .
O e i gQ e
i
M de .Diag
edWi hCa ce .T ea
e
C
O e i gQ e
i
M de .Diag
edWi hCa ce .T ea
e
T
O e i gQ e
i
M de .Fi edQ e
O e i gQ e
i
i
i
e e
e
ai eEa ie .Yea
M de .Ha eMedica i
Cha gedI TheLa
ge
ee a
hea h ca e
ide i
ea i
hi ca ce
diag
i
T
M Ca ce
ea e i
c
e e
N
T
N/A
e:
Yea :
6
P ea e i
each
edica i
ha
a
cha ged
ha
h .
ed
a i ga d
he ea
he
edica i
egi e a
cha ged
ed
e
1999
N/A
Opthalmolog
ID
Question T
O
ha
g M de .HadVi i
I ha e had
C
ec i
S ge
La i
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51/64
1/18/12
DiagnosisVerification
O
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52/64
1/18/12
DiagnosisVerification
Opthalmolog Model.IrreversibleBlindnessConditionsAnswers.RequireFollowUp
It is
recommend
m health
professiona
I see an
Opthalmolo
for speciali
monitoring
follow up fo
condition.
Opthalmolog Model.IrreversibleBlindnessConditionsAnswers.RequireSpecialAccomodation
I require a
accommoda
for this con
Opthalmolog Model.LatticeDegeneration.date
Date of dia
Opthalmolog Model.LatticeDegeneration.ProviderLastSeenDate
When was
last time o
a health ca
provider fo
condition?
Opthalmolog Model.MacularDegeneration.date
Date of dia
Opthalmolog Model.MacularDegeneration.ProviderLastSeenDate
When was
last time o
a health ca
provider fo
condition?
Opthalmolog Model.RetinalDetachmentAnswers.DateOfDiagnosis
Date of dia
Opthalmolog Model.RetinalDetachmentAnswers.E esAffected
Location:
Opthalmolog Model.RetinalDetachmentAnswers.HadSurger
I had surge
to this cond
in the past
ears
Opthalmolog Model.RetinalDetachmentAnswers.HasDiabetes
I have Diab
Opthalmolog Model.RetinalDetachmentAnswers.NeedFollowUp
It is
recommend
m health
professiona
I see an
Opthalmolo
for speciali
monitoring
follow up fo
condition.
Opthalmolog Model.RetinalDetachmentAnswers.NeedFutureSurger
I have bee
need, or m
need, surg
the future
this conditi
Opthalmolog Model.RetinalDetachmentAnswers.NoSightLimitations
This condit
been resol
at least 3 m
and I have
current e e
limitations
restrictions
Opthalmolog Model.RetinalDetachmentAnswers.OpeningQuestion
Diagnosis:
Detachmen
Please resp
all of the b
points belo
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
53/64
1/18/12
DiagnosisVerification
Opthalmolog Model.RetinalDetachmentAnswers.PersonalStatement
Opthalmolog Model.RetinalDetachmentAnswers.SeenInEmergenc Room
I have bee
emergenc
or urgent c
center or h
been hosp
in the past
ears beca
this conditi
Opthalmolog Model.RetinitisPigmentosaAnswers.DateOfDiagnosis
Date of dia
Opthalmolog Model.RetinitisPigmentosaAnswers.E esAffected
Location:
Opthalmolog Model.RetinitisPigmentosaAnswers.HadSurger
I had surge
to this cond
in the past
ears
Opthalmolog Model.RetinitisPigmentosaAnswers.HasDiabetes
I have Diab
It is
recommend
m health
professiona
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
54/64
1/18/12
DiagnosisVerification
Opthalmolog Model.RetinitisPigmentosaAnswers.NeedFollowUp
I see an
Opthalmolo
for speciali
monitoring
follow up fo
condition.
I have bee
need, or m
need, surg
the future
this conditi
Opthalmolog Model.RetinitisPigmentosaAnswers.NeedFutureSurger
Opthalmolog Model.RetinitisPigmentosaAnswers.NoSightLimitations
This condit
been resol
at least 3 m
and I have
current e e
limitations
restrictions
Opthalmolog Model.RetinitisPigmentosaAnswers.OpeningQuestion
Diagnosis:
Retinitis
Pigmentosa
Opthalmolog Model.RetinitisPigmentosaAnswers.SeenInEmergenc Room
I have bee
emergenc
or urgent c
center or h
been hosp
in the past
ears beca
this conditi
Opthalmolog Model.IrreversibleBlindnessConditionsAnswers.IrreversibleBlindness.date
Date of dia
Opthalmolog Model.IrreversibleBlindnessConditionsAnswers.IrreversibleBlindnessCauseKnown.
Description
(Describe):
Opthalmolog Model.IrreversibleBlindnessConditionsAnswers.RequireFollowUp.Description
(Describe):
Opthalmolog Model.IrreversibleBlindnessConditionsAnswers.RequireSpecialAccomodation.
Description
(Describe):
Opthalmolog Model.RetinalDetachmentAnswers.NeedFollowUp.Describe
(Describe):
Opthalmolog Model.RetinalDetachmentAnswers.NeedFutureSurger .Description
(Describe):
Opthalmolog Model.RetinalDetachmentAnswers.NoSightLimitations.DateOfResolution
Date of dia
Opthalmolog Model.RetinitisPigmentosaAnswers.NeedFollowUp.Describe
(Describe):
Opthalmolog Model.RetinitisPigmentosaAnswers.NeedFutureSurger .Description
(Describe):
Opthalmolog Model.RetinitisPigmentosaAnswers.NoSightLimitations.DateOfResolution
Date of dia
Re pi a o
ID
Q e
Te
RespModel.AsthmaAnswers.ChangedMedicationsInLast3Months
M doctor
changed m
medication in
he pa
h ee mon h
(either
stopped or
started a
medication or
changed the
dosage of a
current
medication)
RespModel.AsthmaAnswers.ConditionResolved
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
ion
An
Te
e
True
This condition
is resolved
without
s mptoms fo
o e a ea , I
have no
restrictions or True
limitations
due to this
condition and
it requires no
55/64
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DiagnosisVerification
RespModel.AsthmaAnswers.Dail Living
further follow
up
This condition
sometimes
impacts on
m abilit to
perform m
activities of
dail living
True
RespModel.AsthmaAnswers.DiagnosisDate
Date of
diagnosis:
1/1/2012
RespModel.AsthmaAnswers.DiagnosticTest
I have had
diagnostic
testing (such
as pulmonar
function
tests) due to
this condition
in the past
two ears
True
RespModel.AsthmaAnswers.Emergenc Room
I have been
to an
emergenc
room or
urgent care
center or
True
have been
hospitali ed
in the past
five ears
because of
this condition.
RespModel.AsthmaAnswers.FollowUpRecommended
It is
recommended
b m health
professional
that I see a
Pulmonologist
(a ph sician
speciali ed in
True
caring for
respirator
conditions)
for
speciali ed
monitoring or
follow up for
this condition.
RespModel.AsthmaAnswers.HasMedications
I require oral
(b mouth) or
inhaled
medication
either dail
or as needed
for this
condition
True
RespModel.AsthmaAnswers.HasS mptoms
I have/had
s mptoms
due to this
condition.
True
RespModel.AsthmaAnswers.IntermittentCondition
This condition
is
intermittent,
triggered b a
specific
True
allergen and
requires
infrequent
use of an
inhaler.
RespModel.AsthmaAnswers.Medications
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
Please list
an
medications
ou are
currentl
taking for this
N/A
56/64
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DiagnosisVerification
condi ion.
Sepa a e
indi id al
medica ion
iha
comma.
Diagno i :
A hma
Re pModel.A hmaAn
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T
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T
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ano he
e pi a o o
ca diac
diagno i
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con ib e o
he
mp om
in hi
condidi on
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e
mp om
ake me p
mo e han
fo
ime pe
mon h
T
e
T
e
T
e
T
e
P lmona
Emboli m
T
e
Sa coido i of
he l ng a d
ake e oid
fo hi
condi ion
T
e
Li
N/A
M
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ion An
e
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Ch onic
Ob
ci e
P lmona
Di ea e
(COPD)
Re pModel.Ba eQ e
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C
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ion An
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ema
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Da e of
e ol ion
1/1/2012
Re pModel.A hmaAn
e
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Da e
1/1/2012
Re pModel.A hmaAn
e
.Follo UpRecommended.De c ip ion
De c ibe
N/A
1/1/2012
N/A
ea on
Re pModel.A hmaAn
e
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Da e of la
mp om
Re pModel.A hmaAn
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Re pModel.A hmaAn
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Re pModel.A hmaAn
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e
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T
e
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Dande
T
e
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D
, Mold,
and/o Pollen
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e
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E e ci e
T
e
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o cold
T
e
Sea onal
Change
T
e
.Ha COPD.Diagno i Da e
Da e of
diagno i :
1/1/2012
.Ha COPD.
When a
he la
ime
o
a a
Heal h Ca e
p o ide fo
hi
condi ion?
1/1/2012
Re pModel.A hmaAn
e
.T igge .E
Re pModel.A hmaAn
e
.T igge .Sea onalChange
Re pModel.Ba eQ e
ion An
Re pModel.Ba eQ e ion An
P o ide La SeenDa e
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
igge
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e
emeHo O Cold
57/64
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DiagnosisVerification
Re pModel.Ba eQ e
Diagno i Da e
ion An
e
.Ha C
icFib o i .
Re pModel.Ba eQ e ion An
P o ide La SeenDa e
e
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Diagno i Da e
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ion An
icFib o i .
ema.
Re pModel.Ba eQ e ion An
P o ide La SeenDa e
e
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Diagno i Da e
e
.Ha P lmona
ion An
ema.
Emboli m.
Re pModel.Ba eQ e ion An
P o ide La SeenDa e
e
.Ha P lmona
Re pModel.Ba eQ e
Diagno i Da e
e
.Ha Sa coido i .
ion An
Re pModel.Ba eQ e ion An
P o ide La SeenDa e
e
Emboli m.
.Ha Sa coido i .
Da e of
diagno i :
1/1/2012
When a
he la
ime
o
a a
Heal h Ca e
p o ide fo
hi
condi ion?
1/1/2012
Da e of
diagno i :
1/1/2012
When a
he la
ime
o
a a
Heal h Ca e
p o ide fo
hi
condi ion?
1/1/2012
Da e of
diagno i :
1/1/2012
When a
he la
ime
o
a a
Heal h Ca e
p o ide fo
hi
condi ion?
1/1/2012
Da e of
diagno i :
1/1/2012
When a
he la
ime
o
a a
Heal h Ca e
p o ide fo
hi
condi ion?
1/1/2012
Re pModel.A hmaAn
e
.T igge .Dande .Da e
Da e of la
mp om
1/1/2012
Re pModel.A hmaAn
e
.T igge .Dande .Li
Li
N/A
Re pModel.A hmaAn
e
.T igge .D
.Da e
Da e of la
mp om
1/1/2012
Re pModel.A hmaAn
e
.T igge .D
.Li
Li
N/A
Re pModel.A hmaAn
e
.T igge .E e ci e.Da e
Da e of la
mp om
1/1/2012
Re pModel.A hmaAn
e
.T igge .E
emeHo O Cold.Da e
Da e of la
mp om
1/1/2012
Re pModel.A hmaAn
e
.T igge .E
emeHo O Cold.Li
Li
N/A
Da e of la
mp om
1/1/2012
Re pModel.A hmaAn
Rheumatolog
e
.T igge .Sea onalChange .Da e
igge
igge
and Immunolog
ID
Question Te t
Ans er
Te t
Imm Model.Ch onicFa ig eS nd omeAn
M doc o
changed m
medica ion in the
past three
months (ei he
opped o
a ed a
medica ion o
changed he
do age of a
c en
medica ion).
T
e
.ChangedMed
e
I ha e had a
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
58/64
1/18/12
DiagnosisVerification
I
M de .Ch
icFa ig eS
d
eA
e
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I
M de .Ch
icFa ig eS
d
eA
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b
d e
he diag
ic
e
in the past
ear d e
hi
c di i .
I e ie
edica i
ei he
dail or as
needed f
hi
c di i .
icTe
e
T
e
I ha e e ic i
ac i i d e
hi c di i
(f e a
e, I
ca '
,
a ).
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e
e
I
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d
eA
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I
M de .Ch
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d
eA
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I ha e/had
d e
hi c di i .
T
.Medica i
P ea e i a
edica i
a e c e
a i gf
hi
c di i .
Se a a e
i di id a
edica i
ih
ac
a.
N/A
I
M de .Ch
icFa ig eS
d
eA
e
ic i
T
I ha e
ed
ch
e ha
ce in T
the past ear d e
hi c di i .
e
Ch
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S d
e
T
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A
S
i g
d ii
T
e
P
De
a
T
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M d c
cha ged
edica i
in the
past three
months (ei he
ed
a ed a
edica i
cha ged he
d age f a
c e
edica i ).
T
e
.C
Thi c di i
ha
bee e
ed
ih
for
over a ear, I
ha e
e ic i
i ia i
d e
hi c di i
a d
i e ie
f he f
.
T
e
I ha e had a
b
d e
he diag
ic
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in the past
ear d e
hi
c di i .
T
e
I
M de .Ch
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d
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map.peacecorps.go /MAP/HHF/DiagnosisVerification/
ii
a
59/64
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DiagnosisVerification
e e ge c
ge ca e
ce e
ha e
bee h
i a i ed
i the past two
ears d e
hi
c di i .
I e ie
edica i
ei he
dail or as
needed f
hi
c di i .
I
M de .Rhe
a
idA
e
.E e ge c R
I
M de .Rhe
a
idA
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I
M de .Rhe
a
idA
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e
T
e
I ha e
g i g
edica
be
d e
hi
c di i .
T
e
I ha e e ic i
ac i i d e
hi c di i
(f e a
e, I
ca '
,
a ).
T
e
e
I
M de .Rhe
a
idA
e
.Ha Re
I
M de .Rhe
a
idA
e
.Ha S
I ha e/had
d e
hi c di i .
T
.Medica i
P ea e i a
edica i
a e c e
a i gf
hi
c di i .
Se a a e
i di id a
edica i
ih
ac
a.
N/A
I
M de .Rhe
a
idA
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ic i
be
T
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I
M de .Rhe
a
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I
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a
idA
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i
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ch
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the past ear d e
hi c di i .
e
Rhe
a
A h ii
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id
T
P ea e e
a
f he b
i
be
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.
H
d
d e
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c
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ac i i ie
f
dai
i i g/
?
Wha i
a
f
a agi g
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C
?
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aSa e e
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N/A
a
ea
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e c ibed
f
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
hi
60/64
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DiagnosisVerification
condi ion.
Do o
ha e an
conce n
ela ed o
hi
condi ion
ha ma
impac on
o
abili
o e
e 27
mon h
i h he
Peace
Co p ? If
o, plea e
de c ibe.
Imm Model.Rhe ma oidAn
e
Imm Model.Rhe ma oidAn
e
Imm Model.Rhe ma oidAn
e
.P o ide La
When a he
la
ime o
e e een b a
heal h ca e
p ofe ional fo
hi condi ion?
SeenDa e
1/1/2012
.U e O he The apie
I c en l
ili e
o he fo m of
he ap in he
ea men of m
T
condi ion
(e e ci e,
ma age, ph ical
he ap ).
e
.WillNeedToSeeSpeciali
I ill need o ee
a peciali o
ha e pecific
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p fo hi
condi ion fo he
ne
h ee ea .
T
e
N/A
Imm Model.Ch onicFa ig eS nd omeAn
e
.ChangedMed . ea on
Li
ea on fo
change:
Imm Model.Ch onicFa ig eS nd omeAn
e
.Diagno i .Da e
Da e of diagno i : 1/1/2012
Imm Model.Ch onicFa ig eS nd omeAn
e
.Ha Re
Li :
Imm Model.Ch onicFa ig eS nd omeAn
e
.S mp om .A eAn Ongoing
ic ion .li
N/A
T
e
Imm Model.Imm Ba eAn
e
.Ank lo ingSpond li i .Da e
Da e of diagno i : 1/1/2012
Imm Model.Imm Ba eAn
P o ide La SeenDa e
e
.Ank lo ingSpond li i .
Imm Model.Imm Ba eAn
e
.Pol m o i i O De ma om o i i .Da e
Imm Model.Imm Ba eAn
P o ide La SeenDa e
e
.Pol m o i i O De ma om o i i .
Imm Model.Imm Ba eAn
e
.P o ia icA h i i .Da e
Da e of diagno i : 1/1/2012
When a he
la
ime o
a
a heal h ca e
p o ide fo hi
condi ion?
When a he
la
ime o
a
a heal h ca e
p o ide fo hi
condi ion?
Da e of diagno i : 1/1/2012
When a he
la
ime o
a
a heal h ca e
p o ide fo hi
condi ion?
1/1/2012
Imm Model.Imm Ba eAn
e
.P o ia icA h i i .P o ide La
Imm Model.Imm Ba eAn
e
.Scle ode ma.Da e
Da e of diagno i : 1/1/2012
.Scle ode ma.P o ide La
When a he
la
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a
a heal h ca e
Imm Model.Imm Ba eAn
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
e
SeenDa e
1/1/2012
SeenDa e
1/1/2012
1/1/2012
61/64
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provider for this
condition?
ImmuModel.ImmuBaseAnswers.SystemicLupusErythematosus.Date
Date of diagnosis: 1/1/2012
ImmuModel.ImmuBaseAnswers.SystemicLupusErythematosus.
ProviderLastSeenDate
When was the
last time you saw
a health care
provider for this
condition?
1/1/2012
ImmuModel.RheumatoidAnswers.ChangedMeds.reasons
List reasons for
change:
N/A
ImmuModel.RheumatoidAnswers.ConditionResolved.date
Date of
resolution:
1/1/2012
ImmuModel.RheumatoidAnswers.HasOngoingMedicalProblems.list
List:
N/A
ImmuModel.RheumatoidAnswers.HasRestrictions.list
List:
N/A
ImmuModel.RheumatoidAnswers.Rheumatoid.date
Date of diagnosis: 1/1/2012
ImmuModel.RheumatoidAnswers.Symptoms.AreAnyOngoing
True
ImmuModel.RheumatoidAnswers.UsesOtherTherapies.list
List:
N/A
ImmuModel.RheumatoidAnswers.WillNeedToSeeSpecialist.description
Describe:
N/A
Urolog
and Nephrolog
ID
Question Te t
UrologyAndNephrologyModel.CysticDisease
Cystic Diseases of the Kidn
UrologyAndNephrologyModel.Glomerulonephritis
Glomerulonephritis
UrologyAndNephrologyModel.Nephrectomy
Nephrectomy, Solitary or
Horseshoe Kidney
UrologyAndNephrologyModel.Nephritis
Nephritis, Renal Failure
UrologyAndNephrologyModel.SeenDoctorInLast24Months
In the past two years I ha
seen a Primary Care Physi
Nephrologist, Urologist or
doctor for a urinary tract,
bladder or kidney condition
you are unsure, click here
list of condition).
UrologyAndNephrologyModel.CysticDisease.DiagnosisDate
Date of diagnosis:
UrologyAndNephrologyModel.CysticDisease.ProviderLastSeenDate
When was the last time yo
a health care provider for t
condition?
UrologyAndNephrologyModel.CystitisAnswers.AbnornmalAnatomyOfUrinaryTract
I am male and I have an
abnormality in the anatom
my urinary tract that is the
cause of my symptoms
UrologyAndNephrologyModel.CystitisAnswers.CausedByInterstitialCystitis
I have been told my sympt
are caused by interstitial c
UrologyAndNephrologyModel.CystitisAnswers.CausedByOtherDisease
I have/had another diseas
process (such as Reiter s
syndrome) that causes thi
condition
UrologyAndNephrologyModel.CystitisAnswers.DateOfDiagnosis
Date of diagnosis:
UrologyAndNephrologyModel.CystitisAnswers.DateOfResolution
Date of resolution:
UrologyAndNephrologyModel.CystitisAnswers.HadDiagnosisInPast6Mnth
I have had blood tests or o
diagnostic testing (such as
ultrasound) in the past 6 m
due to this condition
UrologyAndNephrologyModel.CystitisAnswers.HadSurgery
I had surgery due to this
condition
UrologyAndNephrologyModel.CystitisAnswers.HadSymptoms
I have/had symptoms due
this condition
UrologyAndNephrologyModel.CystitisAnswers.Medications
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
Please list any medications
are currently taking for this
condition. Separate individ
62/64
1/18/12
DiagnosisVerification
UrologyAndNephrologyModel.CystitisAnswers.MoreThanOnce
medications with a comma
I have had this condition m
than once in the last 2 yea
UrologyAndNephrologyModel.CystitisAnswers.NeedFutureSurgery
I have been told I need, o
need, surgery in the future
to this condition
UrologyAndNephrologyModel.CystitisAnswers.NeedToSeeSpecialist
I will need to see a specia
have specific follow up for
condition over the next 3 y
UrologyAndNephrologyModel.CystitisAnswers.NoSymptoms
This condition is resolved
without symptoms for at le
months, I have no restricti
limitations due to this cond
and it requires no further f
up
UrologyAndNephrologyModel.CystitisAnswers.NumberOfTimesInLast2Yrs
List number of times
UrologyAndNephrologyModel.CystitisAnswers.OpeningQuestion
Diagnosis: Cystitis (Urinary
Infection, Bladder Infection
Please respond to all of th
bullet points below.
How does this condi
affect your activities
daily living/work?
What is your plan fo
managing any symp
while serving with th
Peace Corps?
UrologyAndNephrologyModel.CystitisAnswers.PersonalStatement
Describe your respo
all treatments presc
for this condition.
Do you have any con
related to this condi
that may impact on
ability to serve 27 m
with the Peace Corp
so, please describe.
UrologyAndNephrologyModel.CystitisAnswers.RequireMedication
I require medication either
or as needed for this cond
UrologyAndNephrologyModel.Glomerulonephritis.AcuteChronic
Glomerulonephritis_AcuteC
UrologyAndNephrologyModel.Glomerulonephritis.DiagnosisDate
Date of diagnosis:
UrologyAndNephrologyModel.Glomerulonephritis.ProviderLastSeenDate
When was the last time yo
a health care provider for t
condition?
UrologyAndNephrologyModel.Nephrectomy.DiagnosisDate
Date of diagnosis:
UrologyAndNephrologyModel.Nephrectomy.ProviderLastSeenDate
When was the last time yo
a health care provider for t
condition?
UrologyAndNephrologyModel.Nephritis.AcuteChronic
Nephritis_AcuteChronic
UrologyAndNephrologyModel.Nephritis.DiagnosisDate
Date of diagnosis:
UrologyAndNephrologyModel.Nephritis.ProviderLastSeenDate
When was the last time yo
a health care provider for t
condition?
UrologyAndNephrologyModel.ProstatitisAnswers.AbnornmalAnatomyOfUrinaryTract
I am male and I have an
abnormality in the anatom
my urinary tract that is the
cause of my symptoms
UrologyAndNephrologyModel.ProstatitisAnswers.CausedByInterstitialCystitis
I have been told my sympt
are caused by interstitial c
UrologyAndNephrologyModel.ProstatitisAnswers.CausedByOtherDisease
map.peacecorps.go /MAP/HHF/DiagnosisVerification/
I have/had another diseas
process (such as Reiter s
syndrome) that causes thi
63/64
1/18/12
DiagnosisVerification
condition
Urolog AndNephrolog Model.ProstatitisAnswers.DateOfDiagnosis
Date of diagnosis:
Urolog AndNephrolog Model.ProstatitisAnswers.HadDiagnosisInPast6Mnth
I have had blood tests or o
diagnostic testing (such as
ultrasound) in the past 6 m
due to this condition
Urolog AndNephrolog Model.ProstatitisAnswers.HadSurger
I had surger due to this
condition
Urolog AndNephrolog Model.ProstatitisAnswers.HadS mptoms
I have/had s mptoms due
this condition
Urolog AndNephrolog Model.ProstatitisAnswers.Medications
Please list an medications
are currentl taking for this
condition. Separate individ
medications with a comma
Urolog AndNephrolog Model.ProstatitisAnswers.MoreThanOnce
I have had this condition m
than once in the last 2 ea
Urolog AndNephrolog Model.ProstatitisAnswers.NeedFutureSurger
I have been told I need, o
need, surger in the future
to this condition
Urolog AndNephrolog Model.ProstatitisAnswers.NumberOfTimesInLast2Yrs
List number of times
Urolog AndNephrolog Model.ProstatitisAnswers.OpeningQuestion
Diagnosis: Prostatitis (Pros
Infection)
Urolog AndNephrolog Model.ProstatitisAnswers.RequireMedication
I require medication either
or as needed for this cond
Urolog AndNephrolog Model.C stitisAnswers.NeedFutureSurger .Desc
Describe:
Urolog AndNephrolog Model.C stitisAnswers.NeedToSeeSpecialist.Desc
Describe:
Urolog AndNephrolog Model.C stitisAnswers.S mptoms.AreAn Ongoing
Urolog AndNephrolog Model.ProstatitisAnswers.NeedFutureSurger .Desc
Describe:
Urolog AndNephrolog Model.ProstatitisAnswers.S mptoms.AreAn Ongoing
All Other Bod
S stems
ID Question Te t Ans er Te t
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I Eli abeth Kehne confirm that all of m previous answer were
truthful and complete to the best of m knowledge.
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Introduction
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Opening Questions
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Cardiovascular
Dermatolog
Endocrinolog
Ear, Nose, Throat
Gastroenterolog
Rheumatolog and
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Neurolog
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Diagnoses
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Signature:
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Date of
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01/01/1970
Eli abeth
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| File Type | application/pdf |
| File Modified | 2012-01-24 |
| File Created | 2012-01-18 |