DS-3026 Medical History and Physical Examination Worksheet

Medical Examination for Immigrant or Refugee Applicant

DS 3026 Paper Form (7-2014)

Medical Examination for Immigrant or Refugee Applicant

OMB: 1405-0113

Document [docx]
Download: docx | pdf


Name (Last, First, MI.)

Exam Date (mm-dd-yyyy)

Birth Date (mm-dd-yyyy)

Passport Number

Alien (Case) Number

1. Past Medical History

No

Yes


No

Yes


Shape1

































Shape17 Shape20 Shape19 Shape18 Shape21 Shape10 Shape9 Shape8 Shape7 Shape2 Shape5 Shape4 Shape3 Shape28 Shape16 Shape26 Shape22 Shape23 Shape11 Shape14 Shape27 Shape15 Shape13 Shape24 Shape25 Shape12 Shape6







































































































































































































































































































































































































































































































































































































































































































































































































































































Shape49 Shape48 Shape44 Shape42 Shape51 Shape37 Shape43 Shape36 Shape35 Shape34 Shape29 Shape33 Shape31 Shape30 Shape56 Shape54 Shape53 Shape52 Shape40 Shape41 Shape38 Shape55 Shape39 Shape45 Shape47 Shape46 Shape50 Shape32






































































































































































































































































































































































































































































































































































































































































































































































































































































































General

Illness or injury requiring hospitalization (including psychiatric)


Cardiology

Hypertension

Congestive heart failure or coronary artery disease

Arrhythmia

Rheumatic heart disease

Congenital heart disease


Pulmonology

Shape58 Shape57































































Tobacco use: Current Former

Asthma

Chronic obstructive pulmonary disease

Shape59

Tuberculosis history: Diagnosed (mm-yyyy)

Shape60

Treated (mm-yyyy)

Fever

Cough

Night sweats

Weight loss


Psychiatry

Major impairment in learning, intelligence, self-care, memory, or communication

Major mental disorder (including bipolar disorder, major depression, mental retardation, post-traumatic stress disorder, schizoaffective disorder, schizophrenia)

Use of drugs other than those required for medical reasons

Addiction (dependence) or abuse of specific substances or drugs on the CSA

Other substance related disorders (including alcohol abuse or dependence)

Ever caused serious injury to others, caused major property damage or had trouble with the law because of medical condition, mental disorder, or influence of alcohol or drugs

Ever had thoughts of harming yourself

Ever acted on those thoughts

Ever had thoughts of harming others

Ever acted on those thoughts


Neurology

History of stroke

Seizure disorder


Applicant appears to be providing unreliable or false information, specify in remarks

Shape82 Shape68 Shape79 Shape80 Shape78 Shape77 Shape76 Shape75 Shape74 Shape64 Shape66 Shape65 Shape61 Shape63 Shape70 Shape81 Shape67 Shape71 Shape72 Shape69 Shape73 Shape62












































































































































































































































































































































































































































































































































































































































































































Shape104 Shape98 Shape97 Shape96 Shape91 Shape103 Shape95 Shape90 Shape94 Shape86 Shape87 Shape85 Shape83 Shape88 Shape92 Shape102 Shape89 Shape100 Shape101 Shape99 Shape93 Shape84












































































































































































































































































































































































































































































































































































































































































































Obstetrics and Sexually Transmitted Diseases

Pregnancy, current

Shape105

Estimated delivery date (mm-dd-yyyy)

Shape108 Shape106 Shape107

Pregnancy, birth dates (mm-dd-yyyy)




Shape111 Shape110 Shape109


Previous treatment for sexually transmitted diseases, specify date (mm-yyyy) and treatment:

Shape112

Chancroid

Shape113

Gonorrhea

Shape114

Granuloma inguinale

Shape115

Lymphogranuloma venereum

Shape116

Syphilis


Endocrinology

Diabetes mellitus

Thyroid disease


Hematologic/Lymphatic

Anemia

Sickle Cell Disease

Thalassemia major

Other hemoglobinopathy


Other

Shape117

HIV: if previously tested, mm-yyyy of test

Wears glasses or contact lenses

Shape118

Malignancy, specify:

Chronic renal disease

Chronic liver disease (including hepatitis)

Shape119

Hansen’s Disease: Diagnosed (mm-yyyy)

Shape120

Treated (mm-yyyy)

Shape122 Shape121

Other medical conditions requiring treatment, specify:





Disabilities (including loss of arms or legs), specify:

Shape124 Shape123

2. Current Medications (List all current medications)

Shape126 Shape127 Shape125

3. Previous Surgeries (List all previous surgeries)

Shape128

Shape130 Shape129


Shape131 Shape134 Shape133 Shape132

Photo

OMB No. 1405-0113

EXPIRATION DATE: xx/xx/xxxx

ESTIMATED BURDEN: 30 minutes

(See Page 2 – Back of Form)




U.S. Department of State

MEDICAL HISTORY AND

PHYSICAL EXAMINATION WORKSHEET

For Use with DS-2054





4. Vital Signs and Vision


Shape135

Height cm


Shape136

Weight kg


Shape137

BMI kg/m2





Shape139 Shape138

BP /


Shape140

Pulse / min





Shape141

Temperature ○C


Respiratory

Shape142

Rate / min



Visual acuity at 20 feet:

Shape144 Shape143

Uncorrected L 20/ R 20/

Shape145 Shape146

Corrected L 20/ R 20/

5. Physical Examination (include all findings and give details in Remarks)


N, normal; A, abnormal


N

A


N

A


Shape155 Shape153 Shape152 Shape151 Shape154 Shape147 Shape149 Shape150 Shape148

























































































































































































































































































Shape163 Shape156 Shape159 Shape158 Shape160 Shape157 Shape161 Shape162 Shape164

























































































































































































































































































General appearance

Nutritional status (including acute wasting and or chronic stunting malnutrition)

Hearing and ears

Eyes

Nose, mouth, and throat (include detail)

Heart (S1, S2, murmur, rub)

Lungs

Abdomen (including liver, spleen)

Genitalia (including infection(s))

Shape170 Shape167 Shape165 Shape171 Shape166 Shape172 Shape168 Shape169


























































































































































































































































Shape177 Shape174 Shape173 Shape180 Shape179 Shape178 Shape176 Shape175


























































































































































































































































Inguinal region (including adenopathy)

Musculoskeletal system (including gait)

Extremities (including pulses, edema)

Skin (including hypopigmentation or anesthesia consistent with Hansen’s Disease, evidence of self-inflicted injury or injections)

Hematologic (including signs of anemia such as pallor, koilonychia)

Lymph nodes

Nervous system (including nerve enlargement)

Mental status (including mood, intelligence, perception, thought processes, and behavior during examination)



6. Mental Health Specialist

Shape181
































Referral made to mental health specialist. If so, attach report.


7. Syphilis Laboratory Results and Treatment

Shape182
































Laboratory testing not done



Test Name

Date specimen obtained (mm-dd-yyyy)

Positive

Negative

Initial Titer

Screening






Confirmatory






Treated

Shape183
































Yes

Shape184
































No

If treated, therapy:

Shape185
































Benzathine penicillin, 2.4 MU IM

Shape187 Shape186
































Other (therapy, dose):

Shape189 Shape190 Shape188

Date(s) treatment given (mm-dd-yyyy)

Treated by panel physician:

Shape191
































Yes

Shape192
































No

Stage of syphilis (mark one):

Shape193
































Primary

Shape194
































Secondary

Shape195
































Early latent

Shape196
































Late latent or latent of unknown duration


Shape197
































Tertiary

Shape198
































Neurosyphilis

Shape199
































Congenital


8. Diagnosis and Treatment of Other Sexually Transmitted Infections


Shape203 Shape200 Shape202 Shape201

































































































































Infection: Chancroid Gonorrhea Granuloma inguinale Lymphogranuloma venereum


Shape207 Shape206 Shape204 Shape205

































































































































Diagnosed by panel physician: Yes No Treated by panel physician: Yes No


Drug

Dosage

Start Date (mm-dd-yyyy)

End Date (mm-dd-yyyy)












9. Diagnosis and Treatment for Hansen’s Disease


Type of Hansen’s Disease

Shape208
































Multibacillary

Shape209
































Paucibacillary


Treated by panel physician

Shape210
































Yes

Shape211
































No

Treatment

Shape212
































Partial

Shape213
































Completed



Drug

Dosage

Start Date (mm-dd-yyyy)

End Date (mm-dd-yyyy)


















If not treated by panel physician, was referral made by panel physician to another provider for treatment:

Shape214

































Yes. Provide facility name:

Shape216 Shape215

































No

Diagnosis

Shape217

































Initial diagnosis made by panel physician

Shape218

































Initial diagnosis made by non-panel physician before medical evaluation by panel physician

If so, year of diagnosis:

Shape219



10. Remarks

Shape225 Shape224 Shape220 Shape222 Shape223 Shape221


PAPERWORK REDUCTION ACT STATEMENT

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: [email protected]

CONFIDENTIALITY STATEMENT

AUTHORITIES The information asked for on this form is requested pursuant to Section 212(a) and 221(d) and as required by Section 222 of the Immigration and Nationality Act. Section 222(f) provides that the records of the Department of States and of diplomatic and consular offices of the United States pertaining to the issuance and refusal of visas or permits to enter the United States shall be considered confidential and shall be used only for the formulation, amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies of such records may, in the discretion of the Secretary of State, be made available to a court provided the court certifies that the information contained in such records is needed in a case pending before the court.

PURPOSE The U.S. Department of State uses the facts you provide on this form primarily to determine your classification and eligibility for a U.S. immigrant visa. Individuals who fail to submit this form or who do not provide all the requested information may be denied a U.S. immigrant visa. Although furnishing this information is voluntary, failure to provide this information may delay or prevent the processing of your case.

ROUTINE USES If you are issued an immigrant visa and are subsequently admitted to the United States as an immigrant, the Department of Homeland Security will use the information on this form to issue you a Permanent Resident Card, and, if you so indicate, the Social Security Administration will use the information to issue a social security number. The information provided may also be released to federal agencies for law enforcement, counterterrorism and homeland security purposes; to Congress and courts within their sphere of jurisdiction; and to other federal agencies who may need the information to administer or enforce U.S. laws. More information on the Routine Uses for this collection can be found in the System of Records Notice State-24, Medical Records.


Shape226

DRAFT6

DS-3026 Page 3 of 3

08-2011


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCDC User
File Modified0000-00-00
File Created2021-01-27

© 2024 OMB.report | Privacy Policy