Form PC-262-4 Low Body Mass Index Evaluation Form

Peace Corps

LOW BODY MASS INDEX EVALUATION FORM

The individual listed above has applied to serve as a Peace Corps Volunteer and has reported a weight and height indicating a low Body Mass Index (BMI). In cases where the applicant’s Body Mass Index (BMI) is low, the Peace Corps requires additional information.

Note to the Provider: Please be candid and answer all questions. There are many assignments where a Peace Corps Volunteer will need considerable flexibility and physical endurance to adapt to unpredictable housing conditions, climate extremes, or unreliable transportation. The Volunteer will also need heightened awareness of personal safety and increased attention to safe food and drinking water. The food may be very different than food available in the United States, and there may be limited options to control food offerings. Walking long distances on rough terrain and use of squat toilets is not uncommon. During Peace Corps service there may be limited access to Western-trained health professionals. Medical care and resources compared to U.S. health care standards are limited and specialty physicians may be nonexistent. The most accurate representation of this reported BMI is critical for the Peace Corps to make appropriate medical decisions for qualification and placement. Please answer all questions or the form will be considered incomplete and returned to the applicant.

• Current BMI:

• Your clinical assessment of this BMI:

• Any concerns related to the BMI?

• Are there any associated symptoms (such as amenorrhea)?

• Is there a known diagnosis related to this low BMI? 

• If there is a need for baseline testing, please provide all results from these tests (list tests performed):

I certify this information with regard to Body Mass Index is complete and accurate for the applicant listed above.

Physician Signature/Title (MD or DO as required by state law)

Physician Name (Print)

Date Physician License Number/State

Physician Address

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