Form PC-1790S Report of Physical Examination

Applicant Name ______________________________________________________________________________________________________________________

(Last, First, Middle Initial)

Date of Birth__________ /__________ /___________ Medical Case Number:________________________________________________

(Mo/Day/Year)

Guide to Completing Report
of Physical Examination
OMB No.: 0420-0549
Expiration Date: 1/31/2014

Guide to Completing the Report of Physical Examination
The Physical Examination is one of the final pre-service requirements for individuals applying for Peace Corps service. Most Peace
Corps countries have limited access to Western-trained health professionals, and medical resources are seldom as advanced,
or as available, as they are in the United States. In many assignments a Volunteer may be geographically isolated and without
easy access to medical care. It would not be in a Volunteer’s best interest to be placed in an area where adequate support is not
available for existing health problems or new health needs. In order for the Peace Corps to be able to make appropriate medical
decisions regarding qualification and placement, it must have the most accurate and complete description of the applicant’s
current health status and the medical support that will be needed over the next three years.

Privacy 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 members 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.

Burden Statement:
Public reporting burden for this collection of information is estimated to average 90 minutes per applicant and 45 minutes per physician per response.This estimate
includes the time for reviewing instructions and completing the collection of information. An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any 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 - 0549). Do not return the completed form to this address.

Peace Corps · Guide to Completing Report of Physical Examination

PC-1790 S (Revised 08/2012)

Page 1 of 4

Medical Case Number:

Health History
A copy of the applicant’s health history is included in this packet. Please check one of the boxes below:
h The medical history is complete and accurate
h The medical history is not complete and/or not accurate (List changes, including unreported past history and/or new medical
events since the applicant completed this Health History): _____________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
Physician’s Signature _ ________________________________________________________________________________________________________________________________________________________________________

Measurements and Other Findings
Height (feet/inches) Weight (lbs.) Blood Pressure (resting) Pulse bpm (resting) Gross Vision
Right 20/________ h Corrected
Left 20/________ h Uncorrected
complete prescription for eyeglass form if
uncorrected vision of 20/40 or greater

Clinical Examination All Sections MUST be completed by examining physician
Check each item in appropriate column. All systems must be examined.
Please check either normal or abnormal for all applicable questions. The only questions that may not be applicable are the
gender and age-specific questions (Nos. 12 and 15).
Describe each abnormality in detail. Enter item number before each comment. Use additional sheets if necessary.
Normal Abnormal

Normal Abnormal

h h

1. Head and neck

h h

12. Prostate exam (men over 50 only)

h h

2. Nose, sinuses

h h

13. Anus and rectum

h h

3. Mouth and throat

h h

14. Genitalia (include hernia)

h h

4. Thyroid

h h

15. Pelvic exam (females only)

h h

5. Ears

h h

16. Spine

h h

6. Eyes (include fundoscopic exam)

h h

17. Musculoskeletal

h h

7. Lungs and chest

h h

18. Neurologic

h h

8. Breasts

h h

19. Skin, lymphatics

h h

9. Cardiac (rate, rhythm, heart sounds)

h h

20. Identifying marks, scars, tattoos

h h

10. Peripheral pulses

h h

h h

11. Abdomen

21. Psychiatric (specify any significant
cognitive or behavioral observations)

Prior to this visit have you provided medical care to this Candidate? h yes h no
If yes, how many times in the past 12 months have you seen this Candidate? _______________________________

Peace Corps · Guide to Completing Report of Physical Examination

PC-1790 S (Revised 08/2012)

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Medical Case Number:

Medications
Please check one box below. Note that medications include prescribed, over the counter, and any herbal remedies.
h The medications list is complete and accurate, including the dose and frequency.
h The medications listed are not complete and/or not accurate: (Provide a complete list of medications, including dose,_
frequency, and route for all medications the applicant is currently taking):______________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________

Functional Abilities
Please check one box below.
h I have reviewed the positive health history answers that reported decreased functional ability. I believe this is an_
accurate representation of the functional abilities of the applicant to meet his or her Activities of Daily Living.
h There are no reported functional limitations reported on the Health History. I believe this is an accurate representation_
of no functional limitations of the applicant to meet his or her Activities of Daily Living.
h I am reporting functional limitations that were not reported on the Health History:_________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________

Laboratory Evaluation
Documentation of results must be included for this Physical Exam to be complete. (Please upload lab test results to lab test
tasks on your MAP).
Abnormal lab results require an explanation, a treatment plan or, if chronic abnormality exists, historical results with a plan for
follow up.
Tuberculin Test

Other Required Lab Tests

TB test performed no more than six months prior to physical
exam

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

h 5 TU PPD Date read _______________________________

h HIV (bloodwork or rapid oral test)

Size of induration must be recorded in box below.

h CBC

Do not report “Negative”

h Hepatitis B surface Antigen

mm of induration

h Hepatitis C Antibody
h G6PD titer

OR

A blood test was done in lieu of the PPD

h Basic Metabolic Panel
h Urinalysis

h T SPOT. TB (negative or postive)
h QuantiFERON® - TB gold (lab report must be attached)
h negative h positive

Peace Corps · Guide to Completing Report of Physical Examination

PC-1790 S (Revised 08/2012)

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Medical Case Number:

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

Recommendations for evaluation and/or treatment required for the_
next thee years of service

1__________________________________________________________________________________

_____________________________________________________________________________________________________________

2__________________________________________________________________________________

_____________________________________________________________________________________________________________

3__________________________________________________________________________________

_____________________________________________________________________________________________________________

4_________________________________________________________________________________

_____________________________________________________________________________________________________________

5__________________________________________________________________________________

_____________________________________________________________________________________________________________

6_________________________________________________________________________________

_____________________________________________________________________________________________________________

Do you have any medical concerns about the applicant that might limit his/her assignment to a specific geographic area_
(e.g., mountainous terrain, high altitude, sun exposure, harsh environmental or climatic conditions, etc.)? h yes h no _
If yes, specify:______________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
Understanding that health care resources may be very limited and potentially hours away from his/her living or
working site, do you have any concerns about this applicant serving safely in the Peace Corps? h yes h no _
If yes, specify:______________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________

* Important: Medical examination is complete only when:
(Please check all boxes)
h Candidate has signed and dated HIPPA statement on Page 1.
h Examining Provider has signed and dated Page 4.
h All required laboratory results are provided and reviewed, in addition to clinically significant abnormal results (include
recommendations for follow up).
h I have performed the physical exam as noted.
(Must be signed or co-signed by a licensed M.D. or D.O. if exam performed by other than M.D. or D.O.
Physician Signature/Title____________________________________________________________________________________________________________________________________________________________________
Physician Name (Print)________________________________________________________________________________________________________________________________________________________________________
Date_____________________________________________________________________________________________________________________________________________________________________________________________________
Physician License Number/State_______________________________________________________________________________________________________________________________________________________
Physician Address and Phone Number______________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
INCOMPLETE FORMS WILL BE RETURNED TO THE Candidate AND WILL DELAY PROCESSING!
Peace Corps · Guide to Completing Report of Physical Examination

PC-1790 S (Revised 08/2012)

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