Form PC-1789 Health History Form

Peace Corps Health History Form

HHF (PC 1789)

Health History Form (PC 1789)

OMB: 0420-0510

Document [pdf]
Download: pdf | pdf
1/18/12

OMB Control Number 0420-0510
(Expiration Date 08/31/2014)

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Peace Corps

Home

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
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f

ca

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ggage

ad
gh ad

hich

ca if
diffic
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e a e i i g i c di i
(chec a
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C d < 20 deg ee
a D
If a

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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

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diffic

)

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ha a
C

f he ab e b e a e chec ed,
i e i h e e i
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:

)
a

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ea e de c ibe

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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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Peace Corps

e ekehne L g Off

Home

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

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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

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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

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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

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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

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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

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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

map.peacecorps.gov/MAP/HHF/Allerg /Edit

Save

Ne t

14/14

e

1/18/12

map.peacecorps.go /MAP/HHF/Cardiac/Edit

Welcome ekehne Log Off

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Home

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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

1/18/12

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

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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

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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

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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

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:
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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
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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

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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
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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

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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

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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

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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

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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

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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 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

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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 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

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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

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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

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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
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map.peacecorps.go /MAP/HHF/Cardiac/Edit

The c

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Januar 2012

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Januar 2012
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map.peacecorps.go /MAP/HHF/Cardiac/Edit

ie

edica i

ei he dai

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22/24

1/18/12

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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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 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

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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

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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

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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

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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

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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

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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

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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

:

.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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map.peacecorps.gov/MAP/HHF/Endocrinolog /Edit

Welcome ekehne Log Off

Peace Corps

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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
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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

:

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/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

.
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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

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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

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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

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/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

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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

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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

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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

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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
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

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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

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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

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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
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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
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

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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:
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/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

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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 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

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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

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/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

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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
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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

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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
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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
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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

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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.

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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

map.peacecorps.go /MAP/HHF/ENT/Edit

Save

Ne t

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map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit

Welcome ekehne Log Off

Peace Corps

Home

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

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had a

a a d e

f he i ed e

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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
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id
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a dai
P ea e e
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die

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ac i i ie

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die a d d
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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
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g

e a e g

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P ea e e
H

e

e a
d
d e

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f he b

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dif
be

affec

die a d a

id

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ac i i ie

f dai

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die

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/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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map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit

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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map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit

/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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map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit

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
map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit

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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
map.peacecorps.gov/MAP/HHF/Gastroenterolog /Edit

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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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map.peacecorps.gov/MAP/HHF/Gastroenterolog /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) 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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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

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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

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/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 :
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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

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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:

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/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

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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

,

.

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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.
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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

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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

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.
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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
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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
map.peaceco p .go /MAP/HHF/Ne o/Edi

Surger and placement of a Ventricular Shunt
Date of Surger

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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
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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

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

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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
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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

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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:
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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:
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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)
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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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Ne t

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c lo kele al/Edi

Welcome ekehne Log Off

Peace Corps

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e
Opening Q e ion
Alle g
Ca dio a c la
De ma olog
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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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c lo kele al/Edi

/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
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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
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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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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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c lo kele al/Edi

,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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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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c lo kele al/Edi

,I
D

:

Januar 2012

D
)

:A

,

(

,

Le

P

.
H
/

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C

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D

:

Januar 2012
L

:
L
R
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(

)

)

/A

I

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?
:

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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c lo kele al/Edi

,I
D

:

Januar 2012

D
)
Finge

:A

,

(

,
P

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Januar 2012
I
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(

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F

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D

:

Januar 2012
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
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f
Da e f e
i

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ic e i g ( ch a a MRI
h d e
hi c di i

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ed i h
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e ic i
hi c di i
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Xai
f

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:

Januar 2012

Diag
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, diag
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he a
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gh

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De c ibe
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Wha i
hi e e

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ea

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i h he Peace C

? If

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di i

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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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c lo kele al/Edi

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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map.peacecorps.go /MAP/HHF/Infect/Edit

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
map.peacecorps.go /MAP/HHF/Infect/Edit

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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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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 :
map.peacecorps.gov/MAP/HHF/Hematolog /Edit

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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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/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

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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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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:

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/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

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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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/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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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

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/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

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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 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

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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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P

.S

.

/A

I
I
D

:

/A

I
(

D

)

:

/A

M

3
(

)

L

:

/A

I
6
I
2
I

I
H

D

:

.

/A

T
,I
D

:

Januar 2012

D
P
map.peacecorps.gov/MAP/HHF/Hematolog /Edit

:A
)

(
.
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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

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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

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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
O
Q
A
C
D
E
E ,N
,T
G
R
N
M
I
H
G
R
U
O
M
C
D

?:

D
A
I

(

P

)

(

)

.S

.

/A
D

I
H
Q

(

D

)

:

/A

S
I
D

:

,

(

)

/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

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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

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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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Ne t

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Opening Questions
Allerg
Cardiovascular
Dermatolog
Endocrinolog
Ear, Nose, Throat
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Immunolog
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Hematolog
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Opthalmolog
Mental Health
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

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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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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 :

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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

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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) 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

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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

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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 :

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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

.

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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

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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

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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

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Peace Corps

Home

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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
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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
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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

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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

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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 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

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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

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/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.

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/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

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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

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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

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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

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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

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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

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map.peacecorps.gov/MAP/HHF/Urolog AndNephrolog /Edit

Welcome ekehne Log Off

Peace Corps

Home

In m lifetime I have/had:

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

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
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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

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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

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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

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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

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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

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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

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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
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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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/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

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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

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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

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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

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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

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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
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

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/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

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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

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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

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

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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

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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

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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

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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
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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

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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

map.peacecorps.gov/MAP/HHF/Opthalmolog /Edit

Save

Ne t

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map.peacecorps.go /MAP/HHF/MentalHealth/Edit

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
Musculoskeletal
Infectious Disease
Hematolog
G naecolog
Respirator
Urolog and
Nephrolog
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:
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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

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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
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, ea e chec a
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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
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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
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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

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map.peacecorps.go /MAP/HHF/MentalHealth/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 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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map.peacecorps.go /MAP/HHF/MentalHealth/Edit

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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map.peacecorps.go /MAP/HHF/MentalHealth/Edit

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

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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
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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

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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

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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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map.peacecorps.go /MAP/HHF/MentalHealth/Edit

/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

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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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map.peacecorps.go /MAP/HHF/MentalHealth/Edit

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

map.peacecorps.go /MAP/HHF/MentalHealth/Edit

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map.peacecorps.go /MAP/HHF/MentalHealth/Edit

/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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Opening Questions
Allerg
Cardiovascular
Dermatolog
Endocrinolog
Ear, Nose, Throat
Gastroenterolog
Rheumatolog and
Immunolog
Neurolog
Musculoskeletal
Infectious Disease
Hematolog
G naecolog
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Urolog and
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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:

map.peaceco p .go /MAP/HHF/Clo ingQ e ion /Edi

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
map.peaceco p .go /MAP/HHF/Clo ingQ e ion /Edi

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1/18/12

map.peaceco p .go /MAP/HHF/Clo ingQ e ion /Edi

of batteries or electricit for maintenance

Previous

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Ne t

5/5

1/18/12

DiagnosisVerification

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Verification
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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

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DiagnosisVerification
T

M

S

M

.B

O S

A

,I

.N S

D

M

S

M

.B

O S

A

.O

Q

T

:A

,
(

T

),
Back o Spine
P
.
H

/

?

W

P
C

?

D
M

S

M

.B

O S

A

.P

S

N/A

.
D

27

P
C

?I
,
.

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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

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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/

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DiagnosisVerification

M

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ID

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map.peacecorps.go /MAP/HHF/DiagnosisVerification/

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1/18/12

DiagnosisVerification

hi
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dai
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map.peacecorps.go /MAP/HHF/DiagnosisVerification/

e
.

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6/64

1/18/12

DiagnosisVerification
H

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dA e g A

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If I e e ie ce a
eac i , I ha e
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7/64

1/18/12

DiagnosisVerification
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affec
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Peace
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C

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de c ibe.

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dA e g A

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map.peacecorps.go /MAP/HHF/DiagnosisVerification/

A e g A

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If I e e ie ce a
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8/64

1/18/12

DiagnosisVerification
P ea e e
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1/18/12

DiagnosisVerification

edica i
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10/64

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DiagnosisVerification
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Li

N/A

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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/

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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/

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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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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/

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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

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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

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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

.)

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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/

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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

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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

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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

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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

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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

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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

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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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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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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/

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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

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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

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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

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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/

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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

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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/

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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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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/

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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/

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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

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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/

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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:

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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/

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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/

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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

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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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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

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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/

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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

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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

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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

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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

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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

O

ha

g M de .He

O

ha

g M de .La iceDege e a i

La ice
Dege e a

O

ha

g M de .Mac a Dege e a i

Mac a
Dege e a

O

ha

g M de .Re

e Si

C

ec i eS

ge

He e Si
Ke a i i

e Ke a i i

i eP e c i

I e ie
e ci i
c ec i
(
ga e
c
ac )
Peace C

i

g
di c
age
e fc
e e d e
c di i
e ice.
I

O

ha

map.peacecorps.go /MAP/HHF/DiagnosisVerification/

g M de .See D c

I La

24M

h

he a
ea I ha
aP i a C
Ph icia
O h ha
(e e)
eci
f a c di
gica
ced e
e e (If
e, c ic

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DiagnosisVerification

O

ha

g M de .HadVi i

O

ha

g M de .HadVi i

O

ha

g M de .He

C

C

e Si

ec i eS

ge

ge

.da e

.N F

U Re

M
ge
a ea 3
ag a d I
ge ee
f
e a i e c

i ed

e Ke a i i .da e

Da e

e Ke a i i .P

Whe
a
a
i e
a hea h ca
ide f
c di i ?

ha

g M de .He

O

ha

g M de .I e e

ib eB i d e

C

di i

A

e

.E e Affec ed

L ca i

O

ha

g M de .I e e

ib eB i d e

C

di i

A

e

.I e e

ib eB i d e

I e e ib e
Bi d e

ib eB i d e

eK

I a gi e
diag
i f
ca e f
i e e ib e
bi d e

eU K

The ea
bi d e
i
a d
ha e a
diag
i

O

ha

ha

g M de .I e e

g M de .I e e

ib eB i d e

ib eB i d e

C

C

ide La

di i

di i

A

A

See Da e

f dia

O

O

e Si

ec i eS

f a i
f
c di i
)
(Da e f

e

e

.I e e

.I e e

ib eB i d e

Ca

Ca

:

P ea e e
a
f he b
i
be

O

ha

map.peacecorps.go /MAP/HHF/DiagnosisVerification/

g M de .I e e

ib eB i d e

C

di i

A

e

.Pe

aSa e e

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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

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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/

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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

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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

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condi ion.
Sepa a e
indi id al
medica ion
iha
comma.
Diagno i :
A hma

Re pModel.A hmaAn

e

.OpeningQ e

Re pModel.A hmaAn

e

.O he A hmaT igge

.O he Diffic l ie

Re pModel.A hmaAn

e

ion

T

e

O he

T

e

I ha e
ano he
e pi a o o
ca diac
diagno i
ha
con ib e o
he
mp om
in hi
condidi on

T

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
Re pModel.A hmaAn

e

.WakingUp

Re pModel.Ba eQ e

ion An

e

.Ha COPD

Ch onic
Ob
ci e
P lmona
Di ea e
(COPD)

Re pModel.Ba eQ e

ion An

e

.Ha C

C

Re pModel.Ba eQ e

ion An

e

.Ha Emph

Re pModel.Ba eQ e

ion An

e

.Ha P lmona

Re pModel.Ba eQ e

ion An

e

icFib o i
ema

ic Fib o i

Emph

Emboli m

.Ha Sa coido i

3Mon h .

ema

Re pModel.A hmaAn
Li

e

.ChangedMedica ion InLa

Re pModel.A hmaAn

e

.Condi ionRe ol ed.Da e

Da e of
e ol ion

1/1/2012

Re pModel.A hmaAn

e

.Eme genc Room.Da e

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

.O he A hmaT igge .Da e

Da e of la
mp om

Re pModel.A hmaAn

e

.O he A hmaT igge .Li

Li

Re pModel.A hmaAn

e

.S mp om .A eAn Ongoing

Re pModel.A hmaAn

e

.T igge .Dande

Re pModel.A hmaAn

e

Re pModel.A hmaAn

e

T

e

Animal
Dande

T

e

.T igge .D

D
, Mold,
and/o Pollen

T

e

.T igge .E e ci e

E e ci e

T

e

E eme ho
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

e

e

emeHo O Cold

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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

.Ha C

Re pModel.Ba eQ e
Diagno i Da e

e

.Ha Emph

ion An

icFib o i .

ema.

Re pModel.Ba eQ e ion An
P o ide La SeenDa e

e

.Ha Emph

Re pModel.Ba eQ e
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/

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I

M de .Ch

icFa ig eS

d

eA

e

.Diag

I

M de .Ch

icFa ig eS

d

eA

e

.Ha Medica i

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 ).

T

e

e

I

M de .Ch

icFa ig eS

d

eA

e

.Ha Re

I

M de .Ch

icFa ig eS

d

eA

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 .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
ic Fa ig e
S d
e

T

e

A
S

i g
d ii

T

e

P
De

a

T

e

T

e

T

e

T

e

.Cha gedMed

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
e
in the past
ear d e
hi
c di i .

T

e

I

M de .Ch

icFa ig eS

d

eA

e

.Mi

I

M de .Ch

icFa ig eS

d

eA

e

.O e i gQ e

I

M de .I

Ba eA

e

.A

I

M de .I

Ba eA

e

.P

I

M de .I

Ba eA

e

.P

I

M de .I

Ba eA

e

.Sc e

I

M de .I

Ba eA

e

.S

I

I

I

M de .Rhe

M de .Rhe

M de .Rhe

a

a

a

idA

idA

idA

e

e

e

i gS

edW

d ii

i i O De

a

ia icA h i i
de

di i

.Diag

Sc e
E

Re

icTe

ii

P

a

e icL

i

he a

ed

S
E

i

ii ;

ia ic A h i i
de

a

e ic L
he a

I ha e bee

map.peacecorps.go /MAP/HHF/DiagnosisVerification/

ii

a

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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

e

.Ha Medica i

I

M de .Rhe

a

idA

e

.Ha O g i gMedica P

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

e

ic i

be

T

I ha e
I

M de .Rhe

a

idA

e

.Mi

edW

I

M de .Rhe

a

idA

e

.O e i gQ e

i

i

ed
ch
e ha
ce in T
the past ear d e
hi c di i .

e

Rhe
a
A h ii

e

id

T

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
I

M de .Rhe

a

idA

e

.Pe

aSa e e

e

e

N/A

a
ea

e

e c ibed
f

map.peacecorps.go /MAP/HHF/DiagnosisVerification/

hi

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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
follo
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
ime o
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

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DiagnosisVerification
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

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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

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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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