Form DS-1622 Medical History and Examination for Foreign Service (For

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

MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE

*OMB APPROVAL NO. 1405-0068
EXPIRATION DATE: xx-xx-xxxxx
ESTIMATED BURDEN: 1 HOUR

FOR CHILDREN 11 YEARS AND UNDER
PRIVACY ACT NOTICE
AUTHORITIES: The information is sought pursuant to the Foreign Service Act of 1980, as amended (22 U.S.C. §§ 4084, 3901, 3984).
PURPOSE: The information solicited on this form will be used to make appropriate medical clearance decisions.
ROUTINE USES: The information on this form maybe shared with personnel in the Office of Medical Services. Unless otherwise protected by medical privacy regulations,
the information may be made available to appropriate agencies, whether Federal, state, local or foreign, for law enforcement and administration purposes. It may also be
disclosed pursuant to court order. More information on the Routine Uses for the system can be found in the System of Records Notice State-24, Medical Records.
DISCLOSURE: Providing this information is voluntary. However, failure to provide the information requested on this form may result in denial of a medical clearance.
PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average one (1) hour per response, including time
required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final
collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this
burden estimate and/or recommendations for reducing it, please send them to: M/MED/EX, Room L217 SA-1, U.S. Department of State, Washington, DC 20522

I. To Be Filled Out By Sponsor Or Parent (Complete all sections, type or in ink.)
1. Name of Examinee (Last, First, MI.)

Date (mm-dd-yyyy)

3. Date of Birth (mm-dd-yyyy)

2. Full Name of Employee/Applicant/Sponsor

4. Sex
Male

5. eMED Number if known (Employee/Applicant/Sponsor)

Female

7. Agency of Employee/Applicant/Sponsor
State

Foreign Commercial
Service

USAID
6. Place of Birth

Board of Broadcasting
Governors

Foreign Agricultural Service
City

State

Country

8. Mailing Address
(Medical Clearance Abstract will be mailed to listed address)

9. Post of Assignment and Dates of Departure/Arrival

a. Proposed Post
EDA
(mm-dd-yyyy)

b. Present Post

Telephone Number
(where you can be
reached for the next
90 days)

EDD
(mm-dd-yyyy)

E-mail Address
c. Last 3 Posts

(where you can be
reached for the
next 90 days)

10. Purpose of Examination
11. Name of Your Health Insurance Plan

a. In-Service

b. Separation

c. New Dependent

12. Is Child Adopted?
Yes

No

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

Name of Examinee

No

Yes
1. Frequent or severe headaches?
2. Dizzy spells, fainting, or seizures?
3. Any neurological disorder?
4. Chronic eye trouble or vision problems?
Date of last eye exam (mm-dd-yyyy)
5. Tooth or gum problems?
6. Ear, nose, or throat problems, including
hearing difficulties, hoarseness, or allergies?
7. Cough, wheezing, shortness of breath or
asthma?
8. Heart murmur or heart problems?
9. Rheumatic fever?
10. Esophagus, stomach, intestinal, rectal, liver,
or gallbladder problems?
11. A change in urinary habits, urinary tract
infection, bedwetting or stones, blood or
protein in urine?
12. Diabetes; thyroid or other hormonal/
metabolic disease?

No
13. Rheumatologic problems; tendon, joint or
back pain/injury; bone deformity or fracture?
14. Malaria or other tropical disease?
15. Any hair, nail or skin problems or disorders?
16. History of positive TB skin test or clinical tuberculosis/
TB exposure or BCG vaccination?
17. Anemia or blood transfusion?
18. Recent gain or loss of 10 lbs or more?
19. Frequent crying spells, trouble sleeping,
sadness, withdrawal, fears, or worries?
20. Difficulty in relaxing or calming down;
feelings of confusion?
21. Low academic functioning or learning
disability or disorders?
22. Behavioral or discipline problems at home or school?
23. Have you ever been referred to or received
mental health treatment?
24. Other?

III. List Current Medications (Include prescription, over the counter, vitamins, and herbals)

IV. Hospitalizations/Operations/Medical Evacuation (Include all medical and psychiatric illnesses)
Illness or Operation
Name of Hospital

Date (mm-dd-yyyy)

Drug Or Other Allergies

City and State

Is there anything else you would like to mention about your child's health or well being? Parent should explain "yes" answers to questions 1-24.

Please recheck all items for completeness and accuracy. DO NOT INDICATE: "Previously Answered"
The intentional omission of any crucial medical information is a criminal offense (Section 1001 of the U.S.C. Title 18). Applicants who intentionally
omit information that would make them ineligible for appointment, will be subject to disciplinary action, including separation for cause.
Signature of Sponsor or Parent (I certify I have read and understand the above statements)
Date (mm-dd-yyyy)

V. To Be Completed By The Examiner (Read section X before proceeding.)
Significant History (Note: The Examiner MUST comment on ALL items checked "YES" in Part II.)

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VI. To Be Completed By The Examiner
1. Height

Name Of Examinee
2. Weight

3. Pulse (must be recorded)

in. or

lb. or

cm.

kg.

percentile

Right 20/

Corrected 20/

Left 20/

Corrected 20/

percentile
6. Head Circumference
(18 months and under)

5. Distant Vision (age 5 and over)

4. Blood Pressure
(age 5 and Over)

in. or
cm.

7. Development Appropriate for Age
Yes
No
Attach development screen if indicated under age 4
8. Immunizations Reviewed
Yes
No
Immunizations current?

VII. Clinical Evaluation
Check each item as indicated. Check "NE" if not evaluated.

Normal Abnormal

NE

Yes
No
Notes
(Describe every abnormality in detail.
Include pertinent item number before each comment.)

1. General/Constitution
2. Skin
3. Eyes
4. Ears/Nose/Throat
5. Neck/Thyroid
6. Lungs/Thorax
7. Breasts
8. Cardiovascular
9. Abdomen
10. Male Genitalia
11. Anus/Rectum/Prostate
12. Musculoskeletal
13. Lymphatic
14. Neurological
15. Female Gynecologic
16. Miscellaneous
17. Papanicolaou done

Not done

Reason if not done

18. Attach cytology report.
Additional Comments

VIII. All of the following tests are required unless otherwise specified (No LAB required for newborns)
6. If not previously done
1. Hematology (age 1 and over) 3. Blood Lead Level
5. Tuberculin Test (5TU PPD)
recommended for all ages 1 and over, including
(recommended for ages 9
those with previous BCG)
mo. up to 6 years)
Date (mm-dd-yyyy)
a. Blood Type
%
Hematocrit
Results
4. Chest X-RAY (for new TB
mm of induration
2. Urinalysis (if previously not
ABO
skin test convertors, or when
done).
indicated).
Previous BCG
Yes
No
(Rh) D
Specific
u
Previous Positive
Yes
No
Gravity
(weak) D
Albumin
Previous Rx completed
Yes
No
Date (mm-dd-yyyy)
Sugar
Date completed (mm-dd-yyyy)
WBC
Yes
No
Results
New Converter (XRay required)
RBC
Treatment:
Casts
Other
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IX. Assessment Or Problem List

Name Of Examinee
Recommendation For Treatment/Further Study

Typed Name of Examiner

Signature

Examining Facility and Telephone Number

Address

Date (mm-dd-yyyy)

X. Instructions to the Examiner

Disposition of Records:
Parent or sponsor must sign on page 2. Medical provider must sign on page 4.
All reports must be in English and identified with the full name and date of birth of the examinee.
Do Not Submit Reports by US Mail.
Do Not Submit Reports by Professional Courier Service (e.g. FedEx or DHL).
Keep originals as a permanent record.
For U.S. Department of State Health Units and Private Health Care Providers:
The preferred method to submit the DS-1622 is to scan and send by email to: [email protected].
If it is not possible to scan, then please fax the DS-1622 to Medical Records at Fax: 703-875-4850.
If you wish to confirm that your exam forms were received please email [email protected].

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