Form PC-1789 Health History Form

Health History Form

OMB No.: 0420-0510
Expiration Date: 00/00/0000

Health History 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 History for International Placement
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 to medically clear more than 85% of all applicants.

Privacy Act Notice
This information is collected under the authority of the Peace Corps Act, 22 U.S.C. 2501 et seq. It will be used primarily for
the purpose of determining your eligibility for Peace Corps service and, if you are invited to serve as a Peace Corps
Volunteer, for the purpose of providing you with medical care during your Peace Corps service. Your disclosure of this
information is voluntary; however, your failure to provide this information will result in the rejection of your application to
become a Peace Corps Volunteer.
This information may be used for the purposes described in the Privacy Act, 5 USC 552a, including the routine uses listed in
the Peace Corps’ System of Records. Among other uses, this information may be used by those Peace Corps staff members
who have a need for such information in the performance of their duties. It may also be disclosed to the Office of Workers’
Compensation Programs in the Department of Labor in connection with claims under the Federal Employees’ Compensation
Act and, when necessary, to a physician, psychiatrist, clinical psychologist or other medical personnel treating you or
involved in your treatment or care. A full list of routine uses for this information can be found on the Peace Corps website
at http://multimedia.peacecorps.gov/multimedia/pdf/policies/systemofrecords.pdf.

Burden Statement
Public reporting burden for this collection of information is estimated to average 45 minutes per applicant. This estimate
includes the time for reviewing instructions and completing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to: FOIA Officer, Peace Corps, 1111 20th Street, NW, Washington, DC 20526
ATTN: PRA (0420 - 0510). Do not return the completed form to this address.

Medical Number:

OMB 0420-0510

Authorization for Peace Corps Use of Medical Information
(Please sign this and return with your HHF. Keep a copy for your 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 information 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 you
sign this authorization, the Peace Corps will not be able to consider your 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 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 needs your health
information for purposes other than medical treatment or payment.
Under the Peace Corps’ medical confidentiality policy, your health information 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:
• evidence of illegal or unauthorized drug use;
• the existence of a medical condition for which you require accommodation, along with the nature of the accommodation;
• information relating to a serious threat to your health or safety or that of any other person;
• information about your non-compliance with medical advice or policies that pose a serious risk of harm to you or someone else;
• the fact that you have been the victim of a physical or sexual assault;
• information needed to ensure proper arrangements for a medical evacuation;
• information about a medical condition if needed to ensure your safety and security or that of another person;
• information about a medical condition that is affecting your performance or well-being;
• information about risky sexual or other behavior that is putting you or someone else at serious risk; and
• information relating to your provision of any misleading, inaccurate or incomplete medical information to the Peace Corps
during the application process.
You may revoke this authorization at any time. However, because this authorization is needed in order for the Peace Corps
to administer its program, you may continue to serve as a Volunteer only for as long as this authorization remains in effect.
Peace Corps · Health History Form

Page 2 of 35

Medical Case Number:

This authorization permits the Peace Corps to use my protected health information to determine my eligibility for the Peace
Corps and as necessary for administration of the Peace Corps program. I understand that this document must be signed,
dated, and returned with my medical information, and that the Peace Corps will be unable to review my information without
this signed document.
I, hereby authorize that:
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 Corps Office of Volunteer Support relating to me prior to my being sworn in as a Peace Corps Volunteer
(including but not limited to information about my prior physical and mental health history, my current health status, and possible
future care and treatment), may be disclosed to the following people:
Peace Corps staff, including in the Office of Volunteer Support , Office of Volunteer Recruitment Selection, Office of Global
Operations, Office of Safety and Security, Office of General Counsel, Peace Corps Medical Officers, Country Directors at
overseas posts, and any other Peace Corps staff or contractors who have a specific need to know the information to perform
their duties, for the purposes of making a determination of my medical or other eligibility for Peace Corps service and of
placement/assignment.
B. If I am accepted for Peace Corps service, the information listed above will become part of my Peace Corps health record.
All information in my Peace Corps health record, and any other personal health information relevant to me that is provided to
the Peace Corps by me or any health care provider or other person, may be disclosed to Peace Corps staff or contractors, as
described in paragraph A above, who have a specific need to know the information for the purposes of performing their duties
in connection with administration of the Peace Corps program only. This may include (but is not limited to) information relevant
to my continued service as a Peace Corps trainee or Peace Corps Volunteer.
This authorization is effective until five years following either my close of Peace Corps service or final determination by the Peace
Corps that I am not eligible for Peace Corps service. I understand that I may revoke this authorization at any time by sending a
written revocation to the Office of Volunteer Support, Peace Corps, 1111 20th Street, NW, Washington DC, 20526, but that my
revocation before acceptance will stop consideration of my application, and that my service as a Volunteer is conditioned on
the existence of this authorization, which is necessary to administer the Peace Corps program.
I also understand that during the entire period of this authorization to use my health care information, Peace Corps will protect the
confidentiality of my health care information, consistent with the Privacy Act, the Health Insurance Portability and Accountability
Act (as applicable), and Peace Corps policies on confidentiality of medical information, as described in the Peace Corps Notice
of Privacy Practices and Peace Corps Manual Section 268.
I have read and understand this authorization.
Signature:_____________________________________________________________________________________________________________Date of Birth:_________________________________________________

Peace Corps · Health History Form

Page 3 of 35

OPENING QUESTIONS
(CHECK BOX)Have

you ever filled out a Health History Questionnaire for the Peace Corps before?

Year:
<>

What is your birth sex?
Select: Male or Female or Other
Is your current gender identity the same as your birth sex?
YES or
NO, <> questions:
1. Have you received medical or mental health care related to your gender identity?
2. Do you require medications to support your identified gender? YES/NO
a. These medications are listed in the medication section (Yes only)
How tall are you? (height in inches):
<>

How much do you weigh? (weight in pounds):
<>
(YES

or NO) Have you had surgery in your lifetime?

If yes, <>
Describe:
Year

Procedure/Reason
for Surgery

Location on
Body

Delete

Add a surgery
I require visits to a health-care provider for a medical, mental health, and/or dental condition
every three to four months or more frequently (medication refills, laboratory or diagnostic testing,
medical or mental health, or dental follow-up, etc.).
(CHECK BOX)

Describe: <>
REPORT OF CURRENT MEDICATIONS

(CHECK BOX)Do

you take any medications, including any regularly taken over-the-counter medications or
herbal remedies?
Please list all medications you are currently taking. If you do not know the strength of a
medication, answer “unknown.”

As you complete this questionnaire, make sure you report each health condition for which you
take prescription medication.
Medication
(Name):

(CHECK BOX) Are

Route:
(oral,
inhaled,
injectable,
topical)

Strength (e.g.
50mg):

Frequency

Condition
being
treated:

Start Date

End Date

any of your listed medications injectable medications?

Are any of your listed medications immunosuppressive medications for a chronic medical
condition (including chronic steroids)?
(CHECK BOX)

(CHECKBOX) Are
<>

any of your listed medications blood thinners for a chronic medical condition?

Do any of your listed medications require refrigeration?

Describe: <>

REPORT OF PHYSICAL ABILITIES
Peace Corps Volunteers serve in countries in conditions that may include remote locations with rugged
terrain or urban sites that require climbing steep, multiple-floor steps while carrying groceries.
Sometimes access to water is limited and walking with buckets of water may be a daily task.
Transportation may mean walking on rough roads, biking on rugged terrain, or relying on mass
transportation with waits up to several hours in weather that is extremely hot or cold. Ice and snow or
constant dust with relentless dry heat or oppressive humidity is common. The questions below are used
to determine your ability to accommodate such conditions, and make placement decisions as
appropriate.
Check all that apply: (If you mark “cannot,” a description is required)

<> I

can walk distances greater than two miles on rough or uneven terrain on a daily basis.

If No, Describe

why not:

<>
<>I

can climb at least two flights of stairs carrying groceries or luggage without difficulty on a daily

basis.
If No, Describe

why not:

<>
<>I

can tolerate riding in a vehicle on rough roads on a daily basis.

If No, Describe

why not:

<>
<>I

can hold a squat position for several minutes to use a squat commode or toilet.

If No, Describe

why not:

<>
<>I

can independently lift or manage my luggage and other supplies during service (up to a weight
of 50 pounds)?
If No, Describe

why not:

<>

I cannot tolerate living in conditions (check all that apply)
Heat >90 degrees (CHECK BOX) Cold <20 degrees (CHECK BOX) Constant dampness (CHECK BOX)
Constant dust

(CHECK BOX)

If any of the above boxes are checked, please describe why you cannot live in those
environments:
<>
<> I

have a medical condition(s) that would prohibit me from living at high
altitudes (more than 5,000 feet above sea level)
If Yes, Please

describe the medical condition:

<>
<> I

living.

have limitations on my functional abilities to meet my activities of daily

If Yes, Describe

the limitations on your functional abilities:

<>

What kind of accommodations do you require?
<>
<> I
If Yes, What

require or use prosthetic device for any part of my body.

kind of prosthetic device do you require?

<>

ALLERGY
(Conditions of Allergic Response)
Life-Threatening Reactions
(Check Box) In

my lifetime I have experienced a life-threatening allergic reaction with some or all of these
symptoms: swelling of the mouth, tongue, lips, and/or difficulty breathing; loss of consciousness;
and/or drop in blood pressure.
Substance that caused a
life-threatening allergic
reaction

Describe your reaction

Date of last reaction

<>

<>

<>

Delete

Add an another substance that caused a life-threatening allergic reaction
(Check Box)

My reaction required an emergency room visit or hospitalization.

Date:
<>

How are you currently managing this condition?
<>

Allergy Shots
(Check Box) I

currently receive allergy shots.

Expected date of final treatment:
<>
(Check Box) In my lifetime, I have had an allergic reaction to one or more of the following: medication,
food, animals, environment, insects or other allergens (See below for a list of conditions).
(Check Box) I

have had no symptoms of an allergic reaction or intolerance.

Select all that apply
(Yes/No Check Box)

Allergy to 3 or more antibiotics

Please list the antibiotic
medications that cause an
allergic reaction

Describe your reaction

Date of last reaction

<>

<>

<>

Add a medication

Delete

(Check Box)

Medication allergens (dropdown)

(Check Box) Sulfa allergy
Name of medication

Describe your reaction

Date of last reaction

<>

<>

<>

Name of medication

Describe your reaction

Date of last reaction

<>

<>

<>

Name of medication

Describe your reaction

Date of last reaction

<>

<>

<>

Delete

Add a sulfa medication
(Check Box)

Penicillin allergy
Delete

Add a penicillin medication
(Check Box)

Tetracycline allergy

Add a tetracycline medication
(Check Box)

Other medication allergies not previously listed

Name of medication

Describe your reaction

Date of last reaction

<>

<>

<>

Describe your reaction

Date of last reaction

<>

<>

Add a medication allergy not previously listed
(Check box)

Food allergens (dropdown)

(Check Box)

Peanut allergy

<>

How are you currently managing this condition?
<>
(Check Box)

It is recommended that I carry an EpiPen.

(Check Box)

I have an inhaler to use during an allergic reaction.

(Check Box)

My treatment requires a prescription medication on most days.

(Check Box)

I use over-the-counter medication to treat my allergies.

(Check Box)

Delete

Other nut allergy

Please list any other nut
that causes an allergic
reaction

Describe your reaction

Date of last reaction

Delete

Delete

<>

<>

<>

Delete

Add another nut for which you are allergic
How are you currently managing this condition?
<>
(Check Box)
(Check Box)

It is recommended that I carry an EpiPen.

I have an inhaler to use during an allergic reaction.

(Check Box)

My treatment requires a prescription medication on most days.

(Check Box)

I use over-the-counter medication to treat my allergies.

(Check Box) Shellfish

allergy

<>

Describe your reaction

Date of last reaction

<>

<>

Delete

How are you currently managing this condition?
<>
(Check Box)

It is recommended that I carry an EpiPen.

(Check Box)

I have an inhaler to use during an allergic reaction.

(Check Box)

My treatment requires a prescription medication on most days.

(Check Box)

I use over-the-counter medication to treat my allergies.

(Check Box)

Eggs or egg protein allergy

<>

Describe your reaction

Date of last reaction

<>

<>

How are you currently managing this condition?

Delete

<>
(Check Box)

It is recommended that I carry an EpiPen.

(Check Box)

I have an inhaler to use during an allergic reaction.

(Check Box)

My treatment requires a prescription medication on most days.

(Check Box)

I use over-the-counter medication to treat my allergies.

(Check Box)

I have been restricted from receiving certain vaccinations due to my egg allergy.

(Check Box)

Other food allergy

Please list any other food

Describe your reaction

Date of last reaction

that causes an allergic
reaction
<>

<>

<>

Delete

Add another food that causes an allergic reaction
How are you currently managing this condition?
<>
(Check Box)

It is recommended that I carry an EpiPen.

(Check Box)

I have an inhaler to use during an allergic reaction.

(Check Box)

My treatment requires a prescription medication on most days.

(Check Box)

I use over-the-counter medication to treat my allergies.

(Check Box)

Severe allergic reaction to animals (dropdown)

(Check Box)

Cat allergy
Describe your reaction

Date of last reaction

<>

<>

Delete

How are you currently managing this condition?
<>
(Check Box)

It is recommended that I carry an EpiPen.

(Check Box)

I have an inhaler to use during an allergic reaction.

(Check Box)
(Check Box)
(Check Box)

My treatment requires a prescription medication on most days.

I use over-the-counter medication to treat my allergies.

Dog allergy
Describe your reaction

Date of last reaction

<>

<>

How are you currently managing this condition?
<>
(Check Box)

It is recommended that I carry an EpiPen.

(Check Box)

I have an inhaler to use during an allergic reaction.

(Check Box)

My treatment requires a prescription medication on most days.

(Check Box)

I use over-the-counter medication to treat my allergies.

Delete

(Check Box)

Other animal allergy (ies)

Please list any other
animal that causes an
allergic reaction

Describe your reaction

Date of last reaction

<>

<>

<>

Delete

Add another animal that causes an allergic reaction
How are you currently managing this condition?
<>
(Check Box)

It is recommended that I carry an EpiPen.

(Check Box)

I have an inhaler to use during an allergic reaction.

(Check Box)

My treatment requires a prescription medication on most days.

(Check Box)

I use over-the-counter medication to treat my allergies.

(Check Box) Severe
(Check Box)

allergic reaction to insects (dropdown)

Bee, wasp, or other insect allergy

Please list the insect that
causes an allergic reaction

Describe your reaction

Date of last reaction

<>

<>

<>

Add another insect that causes an allergic reaction

Delete

How are you currently managing this condition?
<>
(Check Box)

It is recommended that I carry an EpiPen.

(Check Box)

I have an inhaler to use during an allergic reaction.

(Check Box)
(Check Box)

My treatment requires a prescription medication on most days.

I use over-the-counter medication to treat my allergies.

(Check Box)

Severe allergic reaction to environmental allergens (dropdown)

(Check Box)

Dust allergy
Describe your reaction

Date of last reaction

<>

<>

How are you currently managing this condition?
<>

Delete

(Check Box)

It is recommended that I carry an EpiPen.

(Check Box)

I have an inhaler to use during an allergic reaction.
My treatment requires a prescription medication on most days.

(Check Box)
(Check Box)
(Check Box)

I use over-the-counter medication to treat my allergies.

Mold allergy
Describe your reaction

Date of last reaction

<>

<>

Delete

How are you currently managing this condition?
<>
(Check Box)

It is recommended that I carry an EpiPen.

(Check Box)

I have an inhaler to use during an allergic reaction.

(Check Box)
(Check Box)
(Check Box)

My treatment requires a prescription medication on most days.

I use over-the-counter medication to treat my allergies.

Seasonal allergy (pollen, trees, etc.)

Please list any seasonal
substance that causes a
severe allergic reaction

Describe your reaction

Date of last reaction

<>

<>

<>

Add a seasonal substance that causes a severe allergic reaction

Delete

How are you currently managing this condition?
<>
(Check Box)

It is recommended that I carry an EpiPen.

(Check Box)

I have an inhaler to use during an allergic reaction.

(Check Box)

My treatment requires a prescription medication on most days.

(Check Box)
(Check Box)

I use over-the-counter medication to treat my allergies.

Other environmental allergy (ies) not previously listed

Please list any other
environmental
substance(s) that causes a
severe allergic reaction

Describe your reaction

Date of last reaction

<>

<>

<>

Delete

Add another environmental substance that causes a severe allergic reaction
How are you currently managing this condition?
<>
(Check Box)

It is recommended that I carry an EpiPen.

(Check Box)

I have an inhaler to use during an allergic reaction.

(Check Box)

My treatment requires a prescription medication on most days.

(Check Box)
(Check Box)

I use over-the-counter medication to treat my allergies.

Other allergy (ies) not previously listed

Please list any other
substance that causes an
allergic reaction

Describe your reaction

Date of last reaction

<>

<>

<>

Add another substance that causes an allergic reaction
How are you currently managing this condition?
<>
(Check Box)

It is recommended that I carry an EpiPen.

(Check Box)

I have an inhaler to use during an allergic reaction.

(Check Box)

My treatment requires a prescription medication on most days.

(Check Box)

I use over-the-counter medication to treat my allergies.

Delete

CARDIOVASCULAR
(Conditions of the Heart or Blood Vessels)
Have you ever had any of the following?
(CHECK BOX)

Heart or Major Heart Vessel Surgery or Procedures

Diagnosis: <>
Date of surgery or procedure:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECK BOX)

Coronary Heart Disease

Diagnosis: <>
Date of diagnosis:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECK BOX) Congestive Heart

Failure

Date of diagnosis:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECK BOX)

Cardiomyopathy
Date of diagnosis:

<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECK BOX)

Endocarditis
Date of diagnosis:
<>

(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECK BOX) Pericarditis

Date of diagnosis:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECK BOX)

Pulmonary Embolism
Date of diagnosis:
<>

(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECK BOX)

Pacemaker

Date of insertion:
<>

Reason for pacemaker
Describe:

<>
(CHECK BOX)

I am still being treated with a pacemaker.

Describe:
<>
(CHECK BOX) Implantable Defibrillator

Date of insertion:
<>

Reason for implantable defibrillator
Describe:
<>
(CHECK BOX)

I am still being treated with an implantable defibrillator.

Describe:
<>
(CHECK BOX)

Heart defect present since birth that requires specialized care

Describe:
<>
(CHECK BOX) Aneurysm

Type of aneurysm: <>
Date of diagnosis:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECK BOX)

Heart Irregularity or Heart Conduction Disorder

Diagnosis: <>

Date of diagnosis:

<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECK BOX) Marfan’s

Syndrome

Date of diagnosis:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECK BOX) Recurrent

fainting, syncope, or loss of consciousness

Diagnosis:
<>

Date of last occurrence:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECK BOX) Stroke

or stroke-like symptoms

Date of diagnosis:
<>
(Check box) I

am currently being treated for this condition.

Describe:
<>
(CHECK BOX)

Heart valve or septal (hole in the heart) disorder

Diagnosis: <>
Date of diagnosis:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>

Are you currently taking a blood thinning medication, other than aspirin?

(CHECK BOX)

Please explain:
<>
(CHECK BOX)

I am 50 years of age or older.

(CHECK BOX)

I have had an electrocardiogram in the last six months.

YOU MUST CHECK ONE OF THE STATEMENTS BELOW.
In the past two years, I have seen a primary care physician or cardiologist for a heart
or blood vessel condition or a medication refill (see below for a list of conditions).
(CHECK BOX) I have not seen a doctor in the past two years for any heart or blood vessel condition.
(CHECK BOX)

Please check all conditions that apply.
(CHECK BOX)

High blood pressure

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Description:
<>
(CHECK BOX)

High cholesterol or high triglycerides

Date of diagnosis:

<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECKBOX) I

require a specialist for monitoring and/or follow-up for this condition.

Description:
<>
(CHECK BOX)

Peripheral vascular disease

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Description:
<>
(CHECK BOX)

Symptomatic varicose veins (painful and/or past history of varicose veins surgery)

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Description:
<>
(CHECK BOX)

Raynaud’s syndrome

Date of diagnosis:

<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I can only live in certain climates due to the severity of this condition.

Describe:
<>
(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Description:
<>

Any cardiac symptoms (such as fainting or chest pain), diagnosed condition, or cardiac
surgery not previously listed
(CHECK BOX)

(CHECK BOX)

I was given a diagnosis for my symptoms.

Diagnosis:
<>

Date of diagnosis:
<>
(CHECK BOX)

The condition causing my symptoms is not known and I do not have a diagnosis.

Describe symptoms:
<>

Date of initial symptoms:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Description:

<>

Dermatology
(Conditions of the Skin)
In my lifetime, I have had (please choose all that apply):
<>

Skin cancer (melanoma, basal cell carcinoma, squamous cell carcinoma, or other skin

cancer)
Diagnosis: <>
Date of most recent diagnosis:
<>

Where was the lesion on your body?
<>
<> I

require follow up, at least annually.

<>
<>

Other skin lesion(s) (actinic keratosis, moles, or nevi or other pre-cancerous skin tumor or

lesion)
Diagnosis: <>
Date of diagnosis:
<>

List location(s):
<>
<> I

require follow up, at least annually.

<>
<> Are you

currently taking medication for a skin condition (such as steroids, oral
isotretinoins [e.g. Absorica, Accutane, Amnesteem, Claravis, Myorisan, Zenatane], long-term antifungal medication, immunomodulators)?
Please describe:
<>

In the past two years, I have seen a primary care physician, surgeon, or dermatologist for
a skin condition or medication refill (see list of conditions below).
<>

<> I

have not seen a doctor in the past two years for any skin condition.

Please check all conditions that apply.
<>

Acne
Date of diagnosis:
<>

How are you currently managing this condition?
<>
<>

I have prescription medication for this condition.

NOTE: If undergoing treatment with an oral isotretinoin, applicant must be stable for
two months post-treatment with documented normal laboratory studies prior to
clearance for Peace Corps service.
<>

Serious hair loss (alopecia) excluding male pattern baldness.
Date of diagnosis:
<>

How are you currently managing this condition?
<>

Is this caused by another medical condition? (CHECKBOX YES/NO)
If yes, please explain.
<>
<>

I have prescription medication for this condition.

NOTE: The Peace Corps does not provide medication for hair loss for strictly cosmetic
purposes.
(CHECKBOX)

I require a specialist for monitoring and/or follow-up for this condition.
Description:
<>

<>

Pilonidal cyst
Date of diagnosis:
<>

How are you currently managing this condition?
<>
<>

I currently have symptoms.

<>

I have had recurrent infected cysts.

Most recent episode:
<>
<>

Lipoma

List location(s):
<>

Date of diagnosis:
<>

How are you currently managing this condition?
<>
<>

Herpes zoster (shingles)
Date of diagnosis:
<>

How are you currently managing this condition?
<>
<>

Rosacea
Date of diagnosis:
<>

How are you currently managing this condition?
<>
<>

Eczema
Date of diagnosis:
<>

Location and extent:
<>

How are you currently managing this condition?
<>
<>
(CHECKBOX)

I have prescription medication for this condition.

I require a specialist for monitoring and/or follow-up for this condition.

Description:
<>
<>

Psoriasis
Date of diagnosis:
<>

Location and extent:
<>

How are you currently managing this condition?
<>
<>
(CHECKBOX)

I have prescription medication for this condition.

I require a specialist for monitoring and/or follow-up for this condition.

Description:
<>
<>

Non-genital warts
Date of diagnosis:
<>

Location and extent:
<>

How are you currently managing this condition?
<>
<>

Genital warts

Date of diagnosis:
<>

Location and extent:
<>

How are you currently managing this condition?
<>
<>

I have prescription medication for this condition.

<>

I have had recurrent episodes.

Most recent episode:
<>
(CHECKBOX)

I require a specialist for monitoring and/or follow-up for this condition.

Description:
<>
<> Any skin symptom (such as a rash, itching, or dry skin), diagnosed condition, or skin
surgery not previously listed.

How are you currently managing this condition?
<>
<>

I was given a diagnosis for my symptoms.

List diagnosis:
<>

Date of diagnosis:
<>

I do not know the name of condition causing my symptoms or I have not
been given a diagnosis.

<>

Date of initial symptoms:
<>

Location and extent:
<>

<>
(CHECKBOX)

I have prescription medication for this condition.

I require a specialist for monitoring and/or follow-up for this condition.

Description:
<>

ENDOCRINOLOGY
(Diabetes or conditions of the Pituitary, Thyroid, Parathyroid, and Adrenal Glands)
Have you had any of these conditions in your lifetime?
(Check all that apply.)
(Check box) Cancer or carcinoma of the endocrine system (thyroid, pituitary gland, parathyroid glands,
thymus, pancreas, or adrenal glands)

Diagnosis: <> Thyroid, pituitary gland, parathyroid glands, thymus, pancreas, adrenal
glands, other with text box
Date of diagnosis:
<>
(Check box) I

am currently being treated for this condition.

Describe:
<>
(Check box) Non-cancerous

tumor affecting your endocrine system (thyroid, pituitary gland, parathyroid
glands, thymus, pancreas, or adrenal glands)
Diagnosis: <> Thyroid, pituitary gland, parathyroid glands, thymus, pancreas, adrenal
glands, other with text box
Date of diagnosis:
<>
(Check box) I

am currently being treated for this condition.

Describe:
<>
(Check box) Disease

or condition of the pituitary gland

Diagnosis:
<>

Date of diagnosis:
<>
(Check box)

I am currently being treated for this condition.

Describe:
<>
(Check box) Disease

or condition of the adrenal gland (pheochromocytoma, congenital adrenal
hyperplasia, Cushing disease, Addison’s disease)
Diagnosis: <> Pheochromocytoma, congenital adrenal hyperplasia, Cushing disease,
Addison’s disease, or other with text box
Date of diagnosis:
<>

I am currently being treated for this condition.

(Check box)

Describe:
<>
(Check box) Diabetes

mellitus, Type 1

Date of diagnosis:
<>
(Check box)
(Check box)

I currently manage this condition with an insulin pump.

Diabetes mellitus, Type 2

Date of diagnosis:
<>
(Check box)

I require injectable (by a shot) medication either daily or as needed for this condition.

(Check box) Disease

of the thyroid gland (hypothyroidism, hyperthyroidism, Hashimoto’s disease, Grave’s
disease, thyroid storm)
Date of diagnosis:
<>
(Check box)

I am currently being treated for this condition.

Describe:
<>
(Check box) Disease

of the parathyroid gland (hypoparathyroid or hyperparathyroid)

Date of diagnosis:

<>
(Check box)

I am currently being treated for this condition.

Describe:
<>
(Check box) Osteoporosis

Date of diagnosis:
<>
(Check box)

I am currently being treated for this condition.

Describe:
<>
(Check Box)

Other hormone disorder (growth or reproductive or other)

Diagnosis: <> Growth, reproductive, other with text box
Date of diagnosis:
<>

I am currently being treated for this condition. Note: Do not include oral
contraceptives.
(Check box)

Describe:
<>
(Check box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>

YOU MUST CHECK ONE OF THE STATEMENTS BELOW
the past two years, I have seen a primary care physician, endocrinologist, or other
specialist for a condition of the endocrine system (e.g., diabetes or conditions of the pituitary,
thyroid, parathyroid, or adrenal glands) or a medication refill (see below for a list of conditions.)
(Check box) I have not seen a doctor in the past two years for any condition of the endocrine
system.
(Check box) In

Check all conditions or symptoms that apply
(Check box)

Glucose disorder, other than diabetes mellitus, (e.g., hypoglycemia or pre-diabetes)

Diagnosis <> Hypoglycemia, pre-diabetes, or other with text
Date of diagnosis:
<>

How are you currently managing this condition?
Describe:
<
(Check box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(Check box)

Hyperthyroidism or Grave’s disease

Date of diagnosis:
<>

How are you currently managing this condition?
Describe:
<
(Check box)

I have prescription medication for this condition.

(Check box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(Check box)

Hypothyroidism (underactive thyroid)

Date of diagnosis:
<>

How are you currently managing this condition?
Describe:
<
(Check box)

I have prescription medication for this condition.

(Check box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(Check box)

Acromegaly (growth hormone secreting pituitary tumor)

Date of diagnosis:
<>

How are you currently managing this condition?
Describe:
<
(Check box)

I have prescription medication for this condition.

(Check box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(Check box)

Prolactin-secreting pituitary tumor (abnormal milk production in women)

Date of diagnosis:
<>

How are you currently managing this condition?
Describe:
<
(Check box)

I have prescription medication for this condition.

<>
(Check box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(Check box)

Non-functioning (no production of hormones) pituitary tumor

Date of diagnosis:
<>

How are you currently managing this condition?

Describe:
<
(Check box)

I have prescription medication for this condition.

(Check box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(Check box)

Pheochromocytoma

Date of diagnosis:
<>

How are you currently managing this condition?
Describe:
<
(Check box)

I have prescription medication for this condition.

(Check box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(Check box)

Gout

Date of diagnosis:
<>

How are you currently managing this condition?
Describe:
<
(Check box)

I have prescription medication for this condition.

(Check box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>

Reproductive hormone abnormalities (amenorrhea, testosterone/estrogen problems,
polycystic ovary syndrome, or other)
(Check box)

Diagnosis: <> amenorrhea, testosterone/estrogen problems, polycystic ovary
syndrome, or other with text box
Date of diagnosis:
<>

How are you currently managing this condition?
Describe:
<
(Check box)

I have prescription medication for this condition.

(Check box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(Check box) Any endocrine symptom (such as hormonal abnormalities), diagnosed condition, or
endocrine surgery not previously listed for which you have sought medical attention in the past two
years.
(Check box)

I was given a diagnosis for my symptoms.

Diagnosis:
<>

Date of diagnosis:
<>
(Check box)

I do not know the condition or I have not been given a diagnosis.

Date of initial symptoms:
<>

How are you currently managing this condition?
Describe:
<
(Check box)

I have prescription medication for this condition.

(Check box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>

EAR, NOSE, and THROAT
(Conditions of the Ear, Nose, and Throat)

Have you ever had any of the following?
(CHECK BOX)

I have no issues with hearing

(CHECK BOX)

I am hard of hearing

Please select the status that applies to you
<< DROPDOWN>>

I am hard of hearing and I use spoken English as my primary means of
communication.

(CHECK BOX)

I am hard of hearing and I use American Sign Language as my primary means
of communication.
(CHECK BOX)

I am hard of hearing and I use a combination of spoken English and
American Sign Language as my means of communication.

(CHECK BOX)

When and how did hearing loss occur?
<>

Ears affected:
Select: Left or Right or Both
(CHECK BOX)

I have had a hearing evaluation (such as audiometry).

(CHECK BOX)

I require the daily use of a hearing aid(s).

List type, date of purchase, manufacturer, model number, and replacement plan, if any.
<>
(CHECK BOX)

I only require use of a hearing aid(s) in certain situations.
Please provide examples:
<>

(CHECK BOX)

Electricity is required for charging my hearing aid(s) or a dry box.

(CHECK BOX) My

hearing aid(s) may need to be replaced in the next three years.

Date of expected future replacement and what is your plan?

<>

I currently use support modalities and/or assistive technology to manage daily
activities and work.

(CHECK BOX)

<>
(CHECK BOX)

I am deaf and (Please select the status that applies to you)

1. Use American Sign Language as my primary means of communication.
When and how did hearing loss occur?
<>

2.

Use both spoken English and American Sign Language as my means of communication.
When and how did hearing loss occur?
<>

3. Use spoken English as my primary means of communication.
When and how did hearing loss occur?
<>

4. I have cochlear implants.
Date of cochlear implant surgery(ies).
<>

I only require use of a cochlear implant sound processor(s) in certain situations rather
than daily.
(CHECK BOX)

Please provide examples:
<>

Date of last mapping for cochlear implant(s)
<>
(CHECK BOX) My

cochlear implant will require mapping during my service.

Describe when and how often:
<>
(CHECK BOX)

Electricity is required for charging my cochlear implant.

I currently use support modalities and/or assistive technology to manage daily
activities and work.

(CHECK BOX)

<>

In my lifetime I have/had:
(CHECK BOX)

Cancer or malignancy of the throat, mouth, tongue, salivary glands, neck
Location: <>
Date of diagnosis
<>

(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
<> I

require follow up, at least annually.
Describe:
<>

(CHECK BOX)Other

growths (non-cancerous) associated with the ear, nose, throat, mouth, tongue, vocal
cords, salivary glands, or neck (e.g., acoustic neuroma, cholesteatoma)
Diagnosis: List with multi-select checkbox
<>

Acoustic neuroma

<>

Cholesteatoma

<>

Other (Please describe)

<>

Date of diagnosis
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<
<> I

require follow up, at least annually.
<>

(CHECK BOX)

Ear, nose, or throat surgery (ear, nose, mouth, tongue, throat, salivary glands, vocal cords,

or neck)
Describe:
<>

Date of surgery
<> (DATE JUST THE YEAR)
<> I

require follow up, at least annually.
<>

(CHECK BOX)

Sleep apnea
Date of diagnosis
<>

(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>

YOU MUST CHECK ONE OF THE STATEMENTS BELOW
In the past two years, I have seen a primary care physician or ear, nose, and throat specialist
for an ear, nose, and throat condition or a medication refill (see below for a list of conditions).
(CHECK BOX)

(CHECK BOX)

I have not seen a doctor in the past two years for any ear, nose, and throat condition.

Please check all conditions that apply.
(CHECK BOX) Recurrent

throat infections (strep, thrush, oral ulcers of mouth, tongue or throat)

Treatment plan:
<>
(CHECK BOX)

Vocal cord disorder

Diagnosis:
<>

Date of diagnosis:
<>

(CHECK BOX)

I am currently being treated for this condition.

<>
(CHECK BOX)

Vertigo (dizziness)

Date of diagnosis:
<>

How are you currently managing this condition?
<>
<>

I currently have moderate to severe symptoms that affect my daily life.

Describe symptoms
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe: <>
(CHECK BOX)

Tinnitus (ringing in the ear)

Date of diagnosis: <>
How are you currently managing this condition?
<>
<>

I currently have moderate to severe symptoms that affect my daily life.

Describe symptoms
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe: <>
(CHECK BOX)

Chronic ear infection

Date of diagnosis: <>
<>

I currently have moderate to severe symptoms that affect my daily life.

Describe symptoms
<>
(CHECK BOX)

I have prescription medication for this condition

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe: <>
(CHECK BOX)

Chronic sinusitis

Date of diagnosis: <>
<>

I currently have moderate to severe symptoms that affect my daily life.

Describe symptoms
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe: <>
(CHECK BOX)

Chronic tonsillitis

Date of diagnosis: <>
<>

I currently have moderate to severe symptoms that affect my daily life.

Describe symptoms
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe: <>
(CHECK BOX)

Recurrent nose bleeds (absent trauma)

Date of diagnosis: <>
<>

I currently have moderate to severe symptoms that affect my daily life.

Describe symptoms
<>

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Description: <>
(CHECK BOX) Any

other symptom or condition of the ear, nose, or throat (including surgeries) not
previously listed that has required you to seek medical attention in the past two years.
How are you currently managing this condition?
<>
(CHECK BOX)

I was given a diagnosis for my symptoms.

List diagnosis
<>

Date: << DATE FIELD>>
I do not know the name of the condition causing my symptoms or I have not
been given a diagnosis.

(CHECK BOX)

Date of initial symptoms
<>
<>

I currently have moderate to severe symptoms that affect my daily life.

Describe symptoms
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require special medical treatment for this condition.

Describe: <>
(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe: <>

GASTROENTEROLOGY
(Conditions of the Colon, Stomach, Pancreas, and Liver)
In my lifetime I have/had:
(CHECK BOX) Cancer

of the gastrointestinal tract (esophagus, stomach, duodenum, liver, gall bladder,
pancreas, appendix, small intestines, colon, rectum, or mesentery)
Actual diagnosis (check all that apply):
Esophagus, stomach, duodenum, liver, gall bladder, pancreas, appendix, small
intestines, colon, rectum, mesentery, or other with text box
<>

Date of most recent diagnosis:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECK BOX) Cirrhosis

of the liver

Date of diagnosis
<>
(Check box)

Hepatitis (inflammation of the liver)

Diagnosis (check at least one box below)
<>
(Check box)

I have prescription medication for this condition.

(Check box) I

am currently being treated for this condition.

Describe:
<>
(CHECK BOX) Any

other diseases of liver or abnormal liver tests (e.g., Gilbert disease, fatty liver, alcoholrelated liver injury, sarcoid liver, malaria, parasitic disease, or gall bladder-related issues)
Diagnosis
<>

Date of diagnosis:
<>

I am currently being treated for this condition.

(CHECK BOX)

Describe:
<>
(CHECK BOX) Gastrointestinal surgery

(esophagus, stomach, gall bladder, intestine, intestinal wall, anus,

or rectum)
Diagnosis:
<>

Date of most recent surgery:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECK BOX) Ulcerative colitis,

Crohn’s, or any other inflammatory bowel disease

Diagnosis (check at least one box below):
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>

(CHECK BOX)
(CHECK BOX) I

I have had treatment with immunosuppressive medication for this condition.

currently have a colostomy, ileostomy, or any other surgical repair of the colon

Describe:
<>
(CHECK BOX) Recurrent

pancreatitis

Date of diagnosis:
<>
(CHECK BOX) I

am currently being treated for this condition.

Describe:
<>
(CHECK BOX) A

history of stricture, obstruction, abscess, fistula, or fissure (i.e., anal fissure)

Diagnosis:
<>

Date of diagnosis:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECK BOX) Gastrointestinal

bleeding (vomiting blood or blood in stools) (e.g., gastritis, peptic ulcer
disease, esophageal varices/tears, hemorrhoids, or other with text box)
Date of diagnosis:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECK BOX)

Lactose intolerance

(CHECK BOX)

I was diagnosed a health-care provider with lactose intolerance.

Date of diagnosis:
<>
(CHECK BOX) Gluten
(CHECK BOX)

intolerance

I was diagnosed by a health-care provider with gluten intolerance.

Date of diagnosis:
<>
(CHECK BOX) Celiac

disease

Date of diagnosis:
<>

PLEASE CHECK AT LEAST ONE OF THE OPTIONS BELOW
(CHECK BOX) I
(CHECK BOX) I

am under 50 years of age
am 50 years of age or older

PLEASE CHECK AT LEAST ONE OF THE FOLLOWING BOXES. CHECK ALL THAT APPLY.
(CHECK BOX)

Colonoscopy (within 10 years)

(CHECK BOX) My
(CHECK BOX)

test was abnormal and required further follow-up testing.

Flexible sigmoidoscopy (within 10 years) and a fecal immunochemical test (FIT) (within

one year)
(CHECK BOX) My
(CHECK BOX)

test was abnormal and required further follow-up testing.

Fecal immunochemical test or high-sensitivity gFOBT (FIT or iFOBT) (within one year)

(CHECK BOX) My
(CHECK BOX)

test was abnormal and required further follow-up testing.

I have not had any of the tests listed above within the defined time frames.

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 or a medication refill (see below for a list of
conditions).
(CHECK BOX) I have not seen a doctor in the past two years for any colon, stomach, pancreas, or
liver condition.
(CHECK BOX)

Please check all conditions that apply

(CHECK BOX)

Acute pancreatitis

Date of diagnosis:
<

How are you currently managing this condition?
Describe:
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX)

Irritable bowel syndrome

Date of diagnosis:
<

How are you currently managing this condition?
Describe:
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX)

Inguinal hernia (protrusion of abdominal contents into the lower abdomen)

Date of diagnosis: <
How are you currently managing this condition?
<>
(CHECK BOX)

I had surgery due to this condition.

Date of surgical repair
<>

(CHECK BOX)

Not surgically repaired

(CHECK BOX) Gastroesophageal

reflux disease (heartburn)

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX)
(CHECK BOX)

I have prescription medication for this condition.
Diverticulitis (inflammation of the lining of the colon)

Date of diagnosis:
<

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX)

Peptic ulcer (a mucosal break in the stomach or small intestine)

Date of diagnosis:
<

How are you currently managing this condition?
Describe:
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX) Gastritis

(inflammation of the mucosa of the stomach)

Date of diagnosis:
<

How are you currently managing this condition?
Describe:
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX)

Internal or external hemorrhoids

Date of diagnosis: <
How are you currently managing this condition?
<>
(CHECK BOX)

I had surgery due to this condition.

Chronic or recurrent abdominal pain (check only if you have not already reported
this condition above)

(CHECK BOX)

(CHECK BOX)

I was given a diagnosis for my symptoms.

Describe:
<>

Date of diagnosis:
<>

I do not know the name of the condition causing my symptoms or I have not been
given a diagnosis.

(CHECK BOX)

Date of initial symptoms:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX) Parasite

disease that affected my gastrointestinal tract

Date of diagnosis: <>
Describe:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECK BOX) Any other intestinal, stomach, pancreas, or liver condition (including surgeries) not
previously listed for which you have sought medical attention in the past two years.
(CHECK BOX)

I was given a diagnosis for my symptoms.

Describe:
<>

Date of diagnosis: <>
I do not know the name of the condition causing my symptoms or I have not been
given a diagnosis.

(CHECK BOX)

Date of initial symptoms:
<>

How are you currently managing this condition?
Describe:
<>
(CHECK BOX)
(CHECK BOX)

I have prescription medication for this condition.

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>

Gynecology
(Conditions of the Female Breast and Female Reproductive System)
In my lifetime, I have had a uterus, ovaries, or female breasts. Yes or No
If yes:
Have you had any of these conditions in your lifetime? (Check all that apply)
(CHECK BOX) Breast cancer

Date of diagnosis:
<>
(CHECK BOX) I

am currently being treated for this condition.

Describe:
<>
(CHECK BOX) Uterine

cancer or endometrial cancer

Date of diagnosis:
<>
(CHECK BOX) I

am currently being treated for this condition.

Describe:
<>
(CHECK BOX) Ovarian

cancer

Date of diagnosis:
<>
(CHECK BOX)I

am currently being treated for this condition.

Describe:
<>
(CHECK BOX) Vaginal

or vulvar cancer

Date of diagnosis:
<>

(CHECK BOX) I

am currently being treated for this condition.

Describe:
<>
(CHECK BOX) Other

gynecological cancer, not previously specified

Date of diagnosis:
<>

Diagnosis:
<>
(CHECK BOX) I

am currently being treated for this condition.

Describe:
<>
(CHECK BOX) History

of gynecological/breast surgeries

Type of surgery:
Describe:
<>

NOTE: The Peace Corps offers routine mammogram screenings for women who are 50 years of age or
older during their service. The Peace Corps follow United States Preventative Services Task Force
recommendations of routine screening mammogram every two years, unless there is a clinical indication
for more frequent screening. Note: Not all countries have the capabilities to provide routine screening
mammograms.
You must check an option below:
will be 50 years of age or older during the time of my Peace Corps service. I would like to
have a routine mammogram screening during my service.
(CHECK BOX) I

will be 50 years of age or older during the time of my Peace Corps service. I would like to
waive my routine mammogram while in service. I realize that if I have risk factors or if my physician
is in disagreement with this decision, I will require site placement where routine mammogram
screenings is provided.
(CHECK BOX) I

(CHECK BOX) I
(CHECK BOX)

will be 50 years of age or younger during the time of my Peace Corps service.

I am over 50 and I have had a mammogram.

Date of last mammogram:
<>

Result of mammogram:
(CHECK BOX)

Normal

(CHECK BOX)

Abnormal

(CHECK BOX)

I am under 50 and I have had a mammogram or sonogram.

Date of last mammogram or sonogram:
<>

Result of mammogram or sonogram:
(CHECK BOX)

Normal

(CHECK BOX)

Abnormal

Please check the option below that describes your most recent Pap result.
(CHECK BOX)

Normal
Date of last Pap: <>

(CHECK BOX)

Abnormal
Date of last Pap: <>

(CHECK BOX)) Never

had a Pap

Check all that apply:
(CHECK BOX) I

have had an abnormal Pap in the past three years.

(CHECK BOX) I

no longer have a cervix and do not need Pap screenings.

Diagnosis:
<>

Date of surgery:
<>
(CHECK BOX) I

have or have had breast implants.

Type of implant:

<>

Date of surgery:
<>
(CHECK BOX)

I am currently on or considering a type of birth control.

Note: The Peace Corps will provide the generic equivalents for most medications. Some methods
of contraception are not available in many countries. These are noted below.
(CHECK BOX)

Oral contraceptive

(CHECK BOX)

Depo-Provera injections

(CHECK BOX)

NuvaRing

Note: It is unlikely the Peace Corps will provide this method of contraception.
(CHECK BOX)

Cervical cap

Note: It is unlikely the Peace Corps will provide this method of contraception.
(CHECK BOX)

Diaphragm

Note: It is unlikely the Peace Corps will provide this method of contraception.
(CHECK BOX)

Intrauterine device (IUD)

Type and duration:
<>

Date of insertion:
Note: If you are considering an IUD but do not yet have one, please use today’s date.
<>

Note: Not all countries will be able to replace an IUD. Therefore, you will need to ensure that
your IUD will not expire during your service.
(CHECK BOX)

Implanted contraception (Nexplanon)

Date of insertion:
<>

Type and duration:
<>

Note: The Peace Corps will not replace contraceptive implants and there may not be an incountry provider who can remove this implant during your service. Therefore, you will need to
ensure that your contraceptive implant will not expire during your service period, or has been
removed or replaced prior to the start of your service.
(CHECK BOX)

Birth control patch

Date:
<>

Name of patch
<>

Note: It is unlikely the Peace Corps will provide this method of birth control.
(CHECK BOX)

Other

Describe:
<>

YOU MUST CHECK ONE OF THE STATEMENTS BELOW:
•

•

Except for routine Pap screenings, in the past two years I have seen a primary care physician or
gynecologist for a condition of the female breast and/or female reproductive organs or a
medication refill (See below for a list of conditions).
I have not seen a doctor in the past two years for any condition of the female breast or female
reproductive system.

Please check all that apply
(CHECK BOX)

Abnormal menstrual cycles (such as no bleeding, infrequent bleeding, heavy or painful

bleeding)
Diagnosis <>
(CHECK BOX)

I have been given a diagnosis for this condition.

Diagnosis:
<>
(CHECK BOX)The

cause of my condition is known.

Describe:
<>

(CHECK BOX)The

cause of my condition is not known.

How are you currently managing this condition?
<>

require a specialist for monitoring and/or follow-up for this condition. Do NOT check
this box for regular visits to the doctor for routine Pap or mammogram visits.
(CHECK BOX)I

Describe:
<>
(CHECK BOX)

Breast lump, solid breast mass, or fibrocystic breast

Diagnosis:
<>

Date of diagnosis:
<>

I require a specialist for monitoring and/or follow-up for this condition. Do NOT check
this box for regular visits to the doctor for routine Pap or mammogram visits.
(CHECK BOX)

Describe:
<>
(CHECK BOX)

Polycystic ovarian disease

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

require a specialist for monitoring and/or follow-up for this condition. Do NOT check
this box for regular visits to the doctor for routine Pap or mammogram visits.
(CHECK BOX)I

Describe:
<>
(CHECK BOX)

Ovarian cyst(s)

Date of diagnosis:

<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

I require a specialist for monitoring and/or follow-up for this condition. Do NOT check
this box for regular visits to the doctor for routine Pap or mammogram visits.
(CHECK BOX)

Describe:
<>
(CHECK BOX)

Endometriosis (uterine lining growing outside of the uterus)

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

I require a specialist for monitoring and/or follow-up for this condition. Do NOT check
this box for regular visits to the doctor for routine Pap or mammogram visits.
(CHECK BOX)

Describe:
<>
(CHECK BOX)

Endometrial hyperplasia (excessive proliferation of the uterine lining)

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

I require a specialist for monitoring and/or follow-up for this condition. Do NOT check
this box for regular visits to the doctor for routine Pap or mammogram visits.
(CHECK BOX)

Describe:
<>

(CHECK BOX) Infected

Bartholin cysts

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

I require a specialist for monitoring and/or follow-up for this condition. Do NOT check
this box for regular visits to the doctor for routine Pap or mammogram visits.
(CHECK BOX)

Describe:
<>
(CHECK BOX)

Genital herpes

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

I require a specialist for monitoring and/or follow-up for this condition. Do NOT check
this box for regular visits to the doctor for routine Pap or mammogram visits.
(CHECK BOX)

Describe:
<>
(CHECK BOX) Genital

ulcers

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

I require a specialist for monitoring and/or follow-up for this condition. Do NOT check
this box for regular visits to the doctor for routine Pap or mammogram visits.
(CHECK BOX)

Describe:
<>
(CHECK BOX)

Genital warts

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

I require a specialist for monitoring and/or follow-up for this condition. Do NOT check
this box for regular visits to the doctor for routine Pap or mammogram visits.
(CHECK BOX)

Describe:
<>
(CHECK BOX)

Fibroids

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

I require a specialist for monitoring and/or follow-up for this condition. Do NOT check
this box for regular visits to the doctor for routine Pap or mammogram visits.
(CHECK BOX)

Describe:
<>
(CHECK BOX) Any gynecological

symptom, diagnosed condition, or gynecological surgery not previously
listed for which you have sought medical attention in the past two years (such as ectopic pregnancy,
pelvic mass, uterine prolapse, uterine fibroids), excluding easily treated sexually transmitted diseases.
Diagnosis:
<>

Date of diagnosis:

<>

How are you currently managing this condition?
<>
(CHECK BOX)I

am currently being treated for this condition.

Describe:
<>
(CHECK BOX)

I have prescription medication for this condition.

I require a specialist for monitoring and/or follow-up for this condition. Do NOT check
this box for regular visits to the doctor for routine Pap or mammogram visits.
(CHECK BOX)

Describe:
<>

HEMATOLOGY
(Conditions of the Blood)
Have you had any of these conditions in your lifetime? (Check all that apply)
(CHECK BOX) Cancer

related to the blood, circulatory system, lymphatic system (e.g., leukemia,
lymphoma, or multiple myeloma)
Diagnosis:
>

Date of diagnosis:
<>
(CHECK BOX) I

am currently being treated for this condition.

Describe:
<>
(CHECK BOX) Bleeding

or clotting disorder (e.g., deep vein thrombosis)

Diagnosis:

Date of diagnosis:
<>
(CHECK BOX) I

am currently being treated for this condition.

Describe:
<>
(CHECK BOX) Hemophilia

Date of diagnosis:
<>
(CHECK BOX) My

spleen has been surgically removed or is non-functioning.

(CHECK BOX) Diagnosis
<>

Date of surgery:

(reason for removal)

<>
(CHECK BOX) Diagnosis

(reason for non-functioning)

<>

Date of diagnosis:
<>
(CHECK BOX) Essential

(primary) thrombocytopenia

Date of diagnosis:
<>
(CHECK BOX) Polycythemia

vera (high red blood cell count)

Date of diagnosis:
<>
(CHECK BOX) Myelofibrosis

Date of diagnosis:
<>
(CHECK BOX) Sickle cell

disease or sickle cell trait

Date of diagnosis:
<>
(CHECK BOX) Thalassemia

or thalassemia trait

Date of diagnosis:
<>
(CHECK BOX) Hemoglobin C

Date of diagnosis:
<>
(CHECK BOX) Hemochromatosis

Date of diagnosis:
<>

(CHECK BOX)

Aplastic anemia (decreased stem cell production)

Date of diagnosis:
<>
(CHECK BOX)I

am currently being treated for this condition.

Describe:
<>
(CHECK BOX) Hemolytic

anemia (breakdown of red blood cells to a disease process)

Select Diagnosis:
(CHECK BOX) Auto-immune

hemolytic anemia

Date of diagnosis:
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Description:
<>
(CHECK BOX)

Hereditary hemolytic anemia

Date of diagnosis:
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition?

Description:
<>
(CHECK BOX)
(CHECK BOX)

Other hemolytic anemia

I was given a diagnosis for my symptoms.

Diagnosis:
<>

Date of diagnosis:

<>

I do not know the name of the condition my symptoms or I have not been given a
diagnosis.
(CHECK BOX)

Date of initial symptoms:
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition?

Description:
<>
(CHECK BOX) Any

other blood disorder

Diagnosis:
<>

Date of diagnosis:
<>
(CHECK BOX) I

am currently being treated for this condition.

Describe:
<>

YOU MUST CHECK ONE OF THE STATEMENTS BELOW
•
•

In the past two years, I have seen a primary care physician or hematologist for a blood condition
or a medication refill (See below for a list of conditions).
I have not seen a doctor in the past two years for any blood condition.

Please check all conditions that apply.
(CHECK BOX)

Iron deficiency anemia

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition?

Description:
<>
(CHECK BOX)

Vitamin B-12 or folate deficiency (megaloblastic/pernicious anemia)

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition?

Description:
<>
(CHECK BOX)

Anemia caused by another condition (such as kidney disease)

(CHECK BOX)

I was given a diagnosis for my symptoms.

Diagnosis:
<>

Date of diagnosis:
<>
(CHECK BOX)

I do not know the name of the condition my symptoms or I have not been given a diagnosis.

Date of initial symptoms:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Description:
<>

(CHECK BOX)

Anemia caused by blood loss (e.g., heavy menses, bleeding ulcer)

Date of diagnosis:
<>

How do you currently manage this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Description:
<>
(CHECK BOX)

A bleeding problem due to a specific medication

Date of diagnosis:
<>

Medication(s) causing bleeding problem:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I required a specialist for monitoring and/or follow-up for this condition.

Description:
<>
(CHECK BOX) Anemia

Diagnosis:
<>

Date of diagnosis:
<>

Date of initial symptoms:
<>

(CHECK BOX)I

am currently being treated for this condition.

Describe:
<>
(CHECK BOX)

I required a specialist for monitoring and/or follow-up for this condition.

Description:
<>

Any other symptom, diagnosed condition, or surgery of the blood or lymphatic system not
previously listed for which you have sought medical attention in the past two years.
(CHECK BOX)

(CHECK BOX)

I was given a diagnosis for my symptoms.

Diagnosis:
<>

Date of diagnosis:
<>

I do not know the name of the condition causing my symptoms or I have not been
given a diagnosis.

(CHECK BOX)

Date of initial symptoms:
<>

How are you managing this condition?
<>
(CHECK BOX)

I require prescription medication daily for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Description:
<>

INFECTIOUS DISEASE
(Conditions of Infectious Process)
In my lifetime I have been diagnosed with:
(Check box)

Human immunodeficiency virus (HIV)

Date of diagnosis:
<>
(Check box)

Hepatitis (inflammation of the liver)

Actual diagnosis (check at least one box below)
<>
(Check box)

I have prescription medication for this condition.

(Check box) I

am currently being treated for this condition.

Describe:
<>
(Check box)

Latent tuberculosis infection (positive skin test or positive blood test)

(Check box)

Active tuberculosis disease

YOU MUST CHECK ONE OF THE STATEMENTS BELOW
In the past two years, I have seen a primary care physician or infectious disease
specialist for an infectious disease or a medication refill (see below for a list of conditions).
(Check box) I have not seen a doctor in the past two years for any infectious disease.
(Check box)

Check all conditions that apply

(Check box)

Diagnosis: Have you had treatment for any sexually transmitted infection in the last two

years.
(Check box)

Syphilis

Date of diagnosis:
<>
(Check box) I

am currently being treated for this condition.

Describe:
<>
(Check box)

Chancroid

Date of diagnosis:
<>
(Check box) I

am currently being treated for this condition.

Describe:
<>
(Check box)

Genital warts (condyloma acuminata)

Date of diagnosis:
<>
(Check box) I

am currently being treated for this condition.

Describe:
<>
(Check box)

Herpes

Location: <>
Date of diagnosis:
<>
(Check box) I

am currently being treated for this condition.

Describe:
<>>

(Check box)

Shingles

Date of diagnosis:
<>
(Check box) I

am currently being treated for this condition.

Describe:
<>
(Check box)

Chronic, frequent, or recurrent bacterial, fungal, viral infection, including thrush

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(Check box) I

am currently being treated for this condition.

Describe:
<>

Any other infectious disease condition or symptom (e.g., dengue, Lyme, malaria, Zika,
amoeba, giardia) or any viral syndromes (e.g., mononucleosis, Epstein Barr virus, cytomegalovirus) not
previously listed for which you have sought medical attention in the past two years (does not include
self-limiting conditions such as a cold, flu, or simple infections)
(Check box)

Diagnosis (check one box below)
(Check box)

I was given a diagnosis for my symptoms.

Describe:
<>
(Check box) I don’t know the name of the condition causing my symptoms or I have not been given
a diagnosis.

How are you currently managing this condition?
<>
(Check box)

I have prescription medication for this condition.

(Check box)

I require a specialist for monitoring and/or follow-up due to this condition.

Describe:
<>

MENTAL HEALTH
(Conditions of Mental Health)
Medication:
I am currently taking or have taken in the past four years medication related to mental health
concerns (e.g., depression, anxiety, ADHD, etc.) (Yes or No)
(If yes to above)
Are you still currently taking any medications? (Yes or No)
(If yes to above)
I have had a change in my medication regimen (type of medication, dose, frequency, etc.)
in the past 12 months. (Yes or No)
(If yes to above)
I currently take three or more medications (including as-needed
medication) related to my mental health concerns (e.g. depression,
anxiety, ADHD, etc.). (Yes or No)
In my LIFETIME, I have been evaluated or treated (including talk-therapy and/or
medication) for the following:
Bipolar spectrum disorder (bipolar I, bipolar II, etc.) (Yes or No)
Evaluation date or date treatment started:
Schizophrenia or a related disorder (schizoaffective disorder, brief psychotic episode, etc.) (Yes
or No)
Evaluation date or date treatment started:
Dissociation-related conditions (dissociative identity disorder, dissociative amnesia, etc.) (Yes or
No)
Evaluation date or date treatment started:
Eating disorder or related behavior (anorexia, bulimia, binge eating disorder, etc.) (Yes or No)
Evaluation date or date treatment started:
Alcohol or substance-related concern (marijuana use disorder, alcohol use disorder—abuse or
dependence, etc.) (Yes or No)
Evaluation date or date treatment started:
Do you regularly attend support meetings in person or online? (Yes or No)
Neurodevelopmental disorder (ADHD, learning disorder, autism spectrum disorder, etc.) (Yes or
No)
Please check all that apply (at least one MUST be selected)

I take or have taken in the past 12 months an amphetamine-type medication, such
as Adderal, Dexadrine.
I take or have taken in the past 12 months an amphetamine-type medication, such
as Vyvanse.
I take or have taken in the past 12 months a stimulant-type medication, such as
Ritalin, Concerta, Focalin.
I take or have taken in the past 12 months an antidepressant-type medication, such
as Strattera, for my neurodevelopmental disorder.
No medication treatment.
I require or have required in the past three years academic support (such as an individual
education plan) or other support to learn or work. (Yes or No)
I have am currently in or have required talk-therapy or counseling in the past for my
neurodevelopmental disorder. (Yes or No)
Personality or conduct disorder (borderline personality disorder, oppositional defiant disorder,
antisocial personality disorder, etc.) (Yes or No)
Evaluation date or date treatment started:
In your LIFETIME, have you ever experienced:
Self-injurious behavior (cutting, scratching, burning, etc.) (Yes or No)
Did you receive treatment (including talk-therapy or medication) for this concern? (Yes
or No)
Suicidal thoughts, gestures, or an attempt to commit suicide (Yes or No)
Did you receive treatment (including talk-therapy or medication) for this concern? (Yes
or No)
A hospitalization for mental health concerns/symptoms (related to suicidal ideation, psychosis,
mania, substance abuse, etc.) (Yes or No)
Most recent hospitalization: Start Date:
Discharge Date:
A partial hospital program, an intensive outpatient program, or a rehabilitation program for
mental health concerns/symptoms (related to suicidal ideation, psychosis, mania, substance
abuse, etc.) (Yes or No)
Date(s):

In the PAST FOUR YEARS, I have been evaluated or treated (including talk-therapy
and/or medication) for the following:
Depression or a related condition (major depressive disorder, persistent depressive disorder, etc.)
(Yes or No)
Evaluation date or date treatment started:
Anxiety or a related condition (generalized anxiety disorder, panic disorder, etc.) (Yes or No)
Evaluation date or date treatment started:
Obsessive or compulsive-related concerns (obsessive-compulsive disorder, body dysmorphic
disorder, etc.) (Yes or No)
Evaluation date or date treatment started:
Trauma or extreme stressor-related concerns (post-traumatic stress disorder, acute stress
disorder, adjustment disorder with depression and/or anxiety, etc.) (Yes or No)
Evaluation date or date treatment started:
Sleep-related concerns (insomnia, hypersomnia, etc.) (Yes or No)
Evaluation date or date treatment started:
Pain or other somatic concern (somatization disorder, conversion disorder, etc.) (Yes or No)
Evaluation date or date treatment started:
Brain injury, memory loss, or other neurocognitive-related concerns (traumatic brain injury,
Alzheimer’s disease, etc.) (Yes or No)
Evaluation date or date treatment started:
Any other mental health-related concern not indicated in any of the fields above. (Yes or No)
Evaluation date or date treatment started:
CURRENTLY or in the past 12 MONTHS I have:
Seen a psychologist, social worker, counselor, therapist, or some other mental health professional
for talk-therapy or counseling for a concern that has not already been identified on this form or in
which my treatment did not/does not include a formal diagnosis. (Yes or No)
Date of last session:
Experienced persistent emotional distress or symptoms related to my mental health for which I
have not yet sought care. (Yes or No)

Musculoskeletal
(Conditions of the Muscles, Bones, Tendons, and Ligaments)
(Check Box) I

have had cancer of the bone or muscle.

Location:
<>

Date of diagnosis:
<>
(Check Box)

I am currently being treated for this condition.

<>

I have a history of non-cancerous bone tumors or other diseases of the bone (Paget’s
disease, fibrous dysplasia)
(Check Box)

Location:
<>

Date of diagnosis:
<>
(Check Box)

I am currently being treated for this condition.

<>

I have had orthopedic surgery in my lifetime and hardware (e.g.: pins, rods, joint
replacement) was left in place.
(Check Box)

Describe the type of surgery(ies), reason for surgery(ies), and what hardware was left in place.
<>

Date of most recent surgery:
<>
(Check Box)

I am currently being treated for this condition.

<>
(Check Box) I have functional limitation(s) or restriction(s) related to conditions of the muscle, bone,
tendon, or ligament condition (Note to applicant: be sure you have selected the related diagnosis
and/or associated condition)

Describe:

<>
(Check Box) I

require medical equipment (brace, mobility assistive devices)

Describe:
<>

YOU MUST CHECK ONE OF THE STATEMENTS BELOW
In the past two years I have seen a primary care physician, orthopedic surgeon, or
other health-care provider (e.g., physical therapist or chiropractor) for a condition of the muscle,
bone, tendon, or ligament or a medication refill (see below for a list of conditions).
(Check Box) I have not seen a doctor in the past two years for any condition of the muscle, bone
tendon, or ligament.
(Check Box)

Please check all conditions that apply.
Any injury, surgery, or pain (on a regular or intermittent basis), or medical care sought for
any reason, in relation to the back or spine
(Check box)

(CHECK BOX)

I was given a diagnosis.

Diagnosis:
<>

Date of diagnosis:
<>
(CHECK BOX)

I do not know the name of the condition or I have not been given a diagnosis.

Date of initial symptoms:
<>
(Check Box)

I had surgery for this condition.

Date of surgery:
<>

How are you currently managing this condition?
<>
(Check Box)
(Check Box)

I require prescription medication daily for this condition.
I require a specialist for monitoring and/or follow-up for this condition.

Describe:

<>

Any injury, surgery, or pain (on a regular or intermittent basis), or medical care sought for
any reason, in relation to the neck
(Check Box)

(CHECK BOX)

I was given a diagnosis.

Diagnosis:
<>

Date of diagnosis:
<>
(CHECK BOX)

I do not know the name of the condition or I have not been given a diagnosis.

Date of initial symptoms:
<>
(Check Box)

I had surgery for this condition.

Date of surgery:
<>

How are you currently managing this condition?
<>

I require prescription medication daily for this condition.

(Check Box)

I require a specialist for monitoring and/or follow-up for this condition.

(Check Box)

Describe:
<>

Any injury, surgery, or pain (on a regular or intermittent basis), or medical care sought for
any reason, in relation to the skull
(Check Box)

(CHECK BOX)

I was given a diagnosis.

Diagnosis:
<>

Date of diagnosis:
<>
(CHECK BOX)

I do not know the name of the condition or I have not been given a diagnosis.

Date of initial symptoms:
<>
(Check Box)

I had surgery for this condition.

Date of surgery:
<>

How are you currently managing this condition?
<>

I require prescription medication daily for this condition.

(Check Box)

I require a specialist for monitoring and/or follow-up for this condition.

(Check Box)

Describe:
<>

Any injury, surgery, or pain (on a regular or intermittent basis), or medical care sought for
any reason, in relation to the knee
(Check Box)

Location:
•
•
•

Left
Right
Both

(CHECK BOX)

I was given a diagnosis.

Diagnosis:
<>

Date of diagnosis:
<>
(CHECK BOX)

I do not know the name of the condition or I have not been given a diagnosis.

Date of initial symptoms:
<>
(Check Box)

I had surgery for this condition.

Date of surgery:
<>

How are you currently managing this condition?
<>

I require prescription medication daily for this condition.

(Check Box)

I require a specialist for monitoring and/or follow-up for this condition.

(Check Box)

Describe:
<>

Any injury, surgery, or pain (on a regular basis or intermittent basis), or medical care sought
for any reason, in relation to the shoulder
(Check Box)

Location:
•
•
•

Left
Right
Both

(CHECK BOX)

I was given a diagnosis.

Diagnosis:
<>

Date of diagnosis:
<>
(CHECK BOX)

I do not know the name of the condition or I have not been given a diagnosis.

Date of initial symptoms:
<>
(Check Box)

I had surgery for this condition.

Date of surgery:
<>

How are you currently managing this condition?
<>
(Check Box)
(Check Box)

Describe:

I require prescription medication daily for this condition.
I require a specialist for monitoring and/or follow-up for this condition.

<>

Any injury, surgery, or pain (on a regular or intermittent basis), or medical care sought for
any reason, in relation to the hand or wrist
(Check Box)

Location:
•
•
•

Left
Right
Both

(CHECK BOX)

I was given a diagnosis.

Diagnosis:
<>

Date of diagnosis:
<>
(CHECK BOX)

I do not know the name of the condition or I have not been given a diagnosis.

Date of initial symptoms:
<>
(Check Box)

I had surgery for this condition.

Date of surgery:
<>

How are you currently managing this condition?
<>
(Check Box)

I require prescription medication daily for this condition.

(Check Box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>

Any injury, surgery, or pain (on a regular or intermittent basis), or medical care sought for
any reason, in relation to the hip or pelvis
(Check Box)

Location:
•

Left

•
•

Right
Both

(CHECK BOX)

I was given a diagnosis.

Describe:
<>

Date of diagnosis: <>
(CHECK BOX)

I do not know the name of the condition or I have not been given a diagnosis.

Date of initial symptoms:
<>
(Check Box)

I had surgery for this condition.

Date of surgery:
<>

How are you currently managing this condition?
<>
(Check Box)

I require prescription medication daily for this condition.

(Check Box)

I require a specialist for monitoring and/or follow-up for this condition.

<>

Any injury, surgery, or pain (on a regular or intermittent basis), or medical care sought for
any reason, in relation to the foot or ankle
(Check Box)

Location:
•
•
•

Left
Right
Both

(CHECK BOX)

I was given a diagnosis.

Describe:
<>

Date of diagnosis: <>
(CHECK BOX)

I do not know the name of the condition or I have not been given a diagnosis.

Date of initial symptoms:
<>
(Check Box)

I had surgery for this condition.

Date of surgery:
<>

How are you currently managing this condition?
<>
(Check Box)

I require prescription medication daily for this condition.

(Check Box)

I require a specialist for monitoring and/or follow-up for this condition.

<>

Any injury, surgery, or pain (on a regular basis), or medical care sought for any reason, in
relation to the elbow
(Check Box)

Location:
•
•
•

Left
Right
Both

(CHECK BOX)

I was given a diagnosis.

Describe:
<>

Date of diagnosis: <>
(CHECK BOX)

I do not know the name of the condition or I have not been given a diagnosis.

Date of initial symptoms:
<>
(Check Box)

I had surgery for this condition.

Date of surgery:
<>

How are you currently managing this condition?
<>

(Check Box)

I require prescription medication daily for this condition.

(Check Box)

I require a specialist for monitoring and/or follow-up for this condition.

<>

Any injury, surgery, or pain (on a regular basis), or medical care sought for any reason, in
relation to the arm
(Check Box)

Location:
•
•
•

Left
Right
Both

(CHECK BOX)

I was given a diagnosis.

Diagnosis:
<>

Date of diagnosis:
<>
(CHECK BOX)

I do not know the name of the condition or I have not been given a diagnosis.

Date of initial symptoms:
<>
(Check Box)

I had surgery for this condition.

Date of surgery:
<>

How are you currently managing this condition?
<>
(Check Box)
(Check Box)

I require prescription medication daily for this condition.
I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>

Any injury, surgery, or pain (on a regular or intermittent basis), or medical care sought for
any reason, in relation to the leg
(Check Box)

Location:
•
•
•

Left
Right
Both

(CHECK BOX)

I was given a diagnosis.

Diagnosis:
<>

Date of diagnosis:
<>
(CHECK BOX)

I do not know the name of the condition or I have not been given a diagnosis.

Date of initial symptoms:
<>
(Check Box)

I had surgery for this condition.

Date of surgery:
<>

How are you currently managing this condition?
<>

I require prescription medication daily for this condition.

(Check Box)

I require a specialist for monitoring and/or follow-up for this condition.

(Check Box)

Describe:
<>

Any injury, surgery, or pain (on a regular or intermittent basis), or medical care sought for
any reason, in relation to the fingers
(Check Box)

(CHECK BOX)

I was given a diagnosis.

Diagnosis:
<>

Date of diagnosis:
<>
(CHECK BOX)

I do not know the name of the condition or I have not been given a diagnosis.

Date of initial symptoms:
<>
(Check Box)

I had surgery for this condition.

Date of surgery:
<>

How are you currently managing this condition?
<>

I require prescription medication daily for this condition.

(Check Box)

I require a specialist for monitoring and/or follow-up for this condition.

(Check Box)

Describe:
<>

Any injury, surgery, or pain (on a regular or intermittent basis), or medical care sought for
any reason, in relation to the toes
(Check Box)

(CHECK BOX)

I was given a diagnosis.

Diagnosis:
<>

Date of diagnosis:
<>
(CHECK BOX)

I do not know the name of the condition or I have not been given a diagnosis.

Date of initial symptoms:
<>
(Check Box)

I had surgery for this condition.

Date of surgery:
<>

How are you currently managing this condition?
<>

I require prescription medication daily for this condition.

(Check Box)

I require a specialist for monitoring and/or follow-up for this condition.

(Check Box)

Describe:
<>

Any injury, surgery, or pain (on a regular or intermittent basis), or medical care sought for
any reason, in relation to any other muscle, bone, tendon, or ligament
(Check Box)

(CHECK BOX)

I was given a diagnosis.

Diagnosis:
<>

Date of diagnosis:
<>
(CHECK BOX)

I do not know the name of the condition or I have not been given a diagnosis.

Date of initial symptoms:
<>
(Check Box)

I had surgery for this condition.

Date of surgery:
<>

How are you currently managing this condition?
<>
(Check Box)
(Check Box)

I require prescription medication daily for this condition.
I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(Check Box)

Osteoporosis (decreased bone mass with increased risk for the bone fracture)

Date of diagnosis:

<>

How are you currently managing this condition?
<>
(Check Box)

I require prescription medication for this condition.

(Check Box)

I have had a fracture in my lifetime due to this condition.

Date(s), location(s) of fracture:
<>
(Check Box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(Check Box)

Osteopenia (low bone mass)

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(Check Box)

I require prescription medication daily for this condition.

(Check Box)

I have had a fracture in my lifetime due to this condition.

Date(s), location(s) of fracture:
<>
(Check Box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(Check Box)

Degenerative Disc Disease (changes to the spinal discs)

Date of diagnosis:
<>

How are you currently managing this condition?
<>

(Check Box)

I require prescription medication daily for this condition.

(Check box) I

have taken steroid or epidural injections.

Most recent:
<>

Frequency:
<>

I sometimes experience numbness or pain in my leg or arm because of compressed
nerve in my neck or back.
(Check Box)

(Check Box)

I have had a fracture in my lifetime due to this condition.

Date(s), location(s) of fracture:
<>
(Check Box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(Check Box)

Degenerative Joint Disease (osteoarthritis)

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(Check Box)
(Check Box)

I require prescription medication daily for this condition.
I have taken steroid or epidural injections.

Most recent:
<>

Frequency:
<>

I sometimes experience numbness or pain in my leg or arm because of a compressed
nerve in my neck or back.
(Check Box)

(Check Box)

I have had a fracture in my lifetime due to this condition.

Date(s), location(s) of fracture:
<>
(Check Box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(Check Box)

Scoliosis (curvature of the spine)

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(Check Box)
(Check Box)

I require prescription medication daily for this condition.

Kyphosis (bowing of the spine)

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(Check Box)

I require prescription medication daily for this condition.

Any other muscle, bone, tendon, or ligament symptom, diagnosed condition, or orthopedic
surgery not previously listed for which you have sought medical attention in the past two years.
(Check Box)

Date of diagnosis:
<>
(Check Box)

I was given a diagnosis for my symptom(s).

Date of diagnosis:
<>

Describe:
<>

I do not know the name of the condition causing my symptoms or I have not been
given a diagnosis.
(Check Box)

Date of initial symptoms:
<>

How are you currently managing this condition?
<>
(Check Box)

I require medication daily for this condition.

(Check Box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>

Neurology
(Conditions of the Brain or Nervous System)
In my lifetime, I have had:
(Check box) A

tumor (cancerous or non-cancerous) of the brain or spinal cord

Diagnosis:
<>

Date of diagnosis:
<>

(Check box) I

am currently being treated for this condition.

Describe:
<>
(Check box) Any

surgery of the brain or spinal cord

Date of diagnosis:
<>

Location:
<>

Reason:
<>
(Check box) Conditions involving blood vessels in your brain (such as brain aneurysm, cerebral vascular
accident, stroke-like symptom, transient ischemic attack)

Diagnosis:
<>

Date of diagnosis:
<>
(Check box)

I had surgery or treatment for this condition.

Date of surgery or treatment:

<>
(Check box)

Surgery and placement of a ventricular shunt

Diagnosis:
<>

Date of diagnosis:
<>

Date of surgery:
<>
(Check box) I

am currently being treated for this condition.

Describe:
<>
(Check box)

A seizure, seizure disorder, or epilepsy (other than a seizure as a baby caused by high fever)

Diagnosis:
<>

Date of diagnosis:
<>

Date of most recent seizure:
<>
(Check box) I

am currently being treated for this condition.

Describe:
<>

Any neuromuscular disorder, motor abnormality, or movement disorder (including tics), that
affects your ability to function (such as amyotrophic lateral sclerosis, multiple sclerosis, Parkinson’s
disease, myasthenia gravis, cerebral palsy, muscular dystrophy, post-polio syndrome, Tourette’s
syndrome, tremors)
(Check box)

Diagnosis:
<>

Date of diagnosis:

<>
(Check box) I

am currently being treated for this condition.

Describe:
<>
(Check box) Any

diagnosis/treatment for concussion, head trauma, or brain injury

Description:
<>

Date of diagnosis:
<>
(Check box) I

am currently being treated for this condition.

Describe:
<>
(CHECK BOX)

Sleep-related condition (such as narcolepsy, insomnia, restless leg syndrome, sleep walking)

Diagnosis:
<>

Date of diagnosis:
<>
(Check box) I

am currently being treated for this condition.

Describe:
<>

YOU MUST CHECK ONE OF THE STATEMENTS BELOW
the past two years, I have seen a primary care physician or neurology (brain or
nervous system) specialist for a condition of the brain or nervous system or a medication refill
(see below for a list of conditions).
(Check box) I have not seen a doctor in the past two years for any condition of the brain or nervous
system.
(Check box)In

(Check box) Have

you had episode(s) of syncope (loss of consciousness or fainting) in the past two years?

Diagnosis:

<

Date of last occurrence:
<>

How are you currently managing this condition?
Describe:
<>
(Check box)

Migraine or other severe headaches

Date of diagnosis:
<>

How are you currently managing this condition?
Describe:
<>
(Check box)

I have prescription medication for this condition.

(Check box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(Check box) Any other symptom, condition, or surgery of the brain or nervous system (e.g., GuillainBarre, peripheral neuropathy) for which you have sought medical attention in the past two years.

(Checkbox) I was given a diagnosis for my symptoms.
Date:
<>

Diagnosis:
<>
(Check box)

I don’t know the name of condition causing my symptoms or I have not been given a diagnosis.

Date of initial symptoms:
<>

How are you currently managing this condition?

Describe:
<>
(Check box)

I have prescription medication for this condition.

(Check box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>

OPHTHALMOLOGY
(Conditions of the Eye)

In my lifetime I have/had:
(CHECK BOX)

Macular degeneration

Date of diagnosis:
<>
(CHECK BOX) Blindness

Please select the status that applies to you:
(CHECK BOX)

I have partial blindness

(CHECK BOX)

I have complete blindness

Location:
•
•
•

Left
Right
Both

When and how did your vision loss occur?
<>
(CHECK BOX) I

was given a diagnosis for the cause of my irreversible blindness.

Describe:
<>
(CHECK BOX)The

reason for my blindness is not known and I do not have a diagnosis.

(CHECK BOX) I

currently use support modalities and/or assistive technology to manage daily
activities and work.
Describe:
<>

(CHECK BOX)

Diabetic retinopathy

Date of diagnosis:
<>

(CHECK BOX)

Ocular lesions (lesions that require scheduled exams, except melanoma)

Date of diagnosis:
<>
(CHECK BOX) Treatment with

injectable drugs into eye (including any immunomodulators) for an eye

condition
Reason for treatment:
<>
(CHECK BOX)

Retinal detachment

Date of diagnosis:
<>

Location:
•
•
•

Left
Right
Both

(CHECK BOX)

Uveitis

Date of diagnosis:
<>
(CHECK BOX)

Optic nerve disease (e.g., optic neuritis)

Date of diagnosis:
<>
(CHECK BOX)

Ophthalmologic (eye) surgery

Reason for surgery:
<>

Date of surgery:
<>
(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>

YOU MUST CHECK ONE OF THE SELECTIONS BELOW:
(CHECK BOX) I

require prescription eye correction (either glasses or contacts).

<>:

Note: The Peace Corps Office of Medical Services strongly discourages Volunteers from
wearing contact lenses while serving abroad, unless there is a medical reason
documented by an ophthalmologist.
(CHECK BOX) I do not require prescription eye correction.
YOU MUST CHECK ONE OF THE SELECTIONS BELOW:
the past two years, I have seen a primary care physician or ophthalmology (eye)
specialist for a condition or surgical procedure for the eyes or a medication refill (see below for a
list of conditions).
(CHECK BOX) I have not seen a doctor in the past two years for any eye condition.
(CHECK BOX) In

Check all conditions or symptoms that apply
(CHECK BOX)

I have had vision correction surgery such as Lasik.

Date of surgery:
<>
(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX)

I am considering having Lasik/photorefractive keratectomy corrective surgery.
Note: A four-month post-operative period is required for medical clearance. Please plan
accordingly.

(CHECK BOX)

I have had temporary blindness.

Diagnosis:
<>

Date of diagnosis:
<>
(CHECK BOX)

Describe:

I require a specialist for monitoring and/or follow-up for this condition.

<>

Herpes infection of the eye that requires prescription medication (i.e., ocular herpes,
shingles, keratitis)
(CHECK BOX)

Date of diagnosis:
<>
(CHECK BOX)

Lattice degeneration

Date of diagnosis:
<>

Location:
•
•
•

Left
Right
Both

How are you currently managing this condition?
<>
(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.
Describe:
<>

(CHECK BOX)

Retinitis pigmentosa
Date of diagnosis:
<>

Location:
•
•
•

Left
Right
Both

How are you currently managing this condition?
<>
(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>

(CHECK BOX)

Cataract(s)

Date of diagnosis:
<>

Location:
•
•
•

Left
Right
Both

How are you currently managing this condition?
<>
(CHECK BOX) I

do not need surgery at this time.

(CHECK BOX) I

had surgery due to this condition.

Date of surgery:
<>
(CHECK BOX) I

have been told I need, or may need, surgery in the future due to this

condition.
Describe:
<>
(CHECK BOX) I

have some limitation with my eyesight due to this condition (such as night

blindness).
Describe:
<>
(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX) Eyelid condition such

Date of diagnosis:
<>

Location:

as chalazion, hordeolum, conjunctivitis, or blepharitis

•
•
•

Left
Right
Both

Date of last occurrence:
<>

How are you currently managing this condition?
<>
(CHECK BOX) I

have prescription medication for this condition.

(CHECK BOX) I

have some limitation with my eyesight due to this condition.

Describe:
<>
(CHECK BOX) I

had surgery due to this condition.

(CHECK BOX) I

have been told I need, or may need, surgery in the future due to this

condition.
Describe:
<>
(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX) Glaucoma

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX) I

have prescription medication for this condition.

(CHECK BOX)I

have some limitation with my eyesight due to this condition.

Describe:
<>

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>

Any other eye symptom, diagnosed condition, or eye surgery not previously listed
for which you have sought medical attention in the past two years
(CHECK BOX)

(CHECK BOX)

I was given a diagnosis for my symptoms.

List diagnosis:
<>

Date:
<>
(CHECK BOX)I

do not know the name of the condition causing my symptoms or I have not
been given a diagnosis.
Date of initial symptoms:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

The cause of this condition is known and can be prevented.

Describe:
<>
(CHECK BOX)I

have some limitation with my eyesight due to this condition.

Describe:
<>
(CHECK BOX) I

had surgery due to this condition in the past two years.

(CHECK BOX) I

have been told I need, or may need, surgery in the future due to this

condition.
Describe:
<>

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>

Respiratory
(Conditions of Breathing and the Lungs)
CHECK ANY TRUE STATEMENT BELOW
In my lifetime I have had (please choose all that apply):
(Check box) Lung

cancer

Date of diagnosis:
<>
(Check box) I

am currently being treated for this condition.

Describe:
<>
(Check box) Surgery

on my lungs

Date of surgery:
<>

Diagnosis:
<>

Type of Surgery: <>
(Check box) I

am currently being treated for this condition.

Describe:
<>
(Check box)

Chronic obstructive pulmonary disease (COPD) (emphysema and/or chronic bronchitis)

Date of diagnosis:
<>
(Check box) I

am currently being treated for this condition.

Describe:
<>

Pulmonary embolism

(Check box)

Date of diagnosis:
<>
(Check box) I

am currently being treated for this condition.

Describe:
<>
(Check box)

Fibrotic lung disease (lung scarring, including sarcoidosis, lupus, idiopathic pulmonary fibrosis,

other) << text box>>
Date of diagnosis:
<>
(Check box) I

am currently being treated for this condition.

Describe:
<>
(Check box)

Cystic fibrosis
Date of diagnosis:
<>

(Check box) I

am currently being treated for this condition.

Describe:
<>
(Check box) Pulmonary

hypertension

Date of diagnosis:
<>
(Check box) I

am currently being treated for this condition.

Describe:
<>
(Check box)

Asthma, reactive airway disease (RAD), or wheezing

(Check box) I

require inhaled medication daily to control asthma symptoms.

YOU MUST CHECK ONE OF THE STATEMENTS BELOW
the past two years, I have seen a primary care physician, allergist, or pulmonologist
for a lung or breathing condition or a medication refill (see below for a list of conditions).
(Check box)I have not seen a doctor in the past two years for any lung condition.
(Check box) In

(Check box)

Asthma, reactive airway disease (RAD), or wheezing
Date of diagnosis:
<>

How are you currently managing this condition?
Describe:
<>
(Check box)

I require oral medication to control my asthma symptoms.

(Check box)

I require inhaled medication to control my asthma symptoms.

(Check box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(Check box)

Pneumothorax (partial or total lung collapse)

Date of diagnosis:
<>
(Check box)

I have had this condition more than once in my lifetime.

List dates:
<>
(Check box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(Check box)

Sleep apnea history (current or resolved)

Date of diagnosis:
<>

How are you currently managing this condition?
Describe:
<>

I require the use of a C-PAP machine to manage.

(Check box)

If yes:
(Check box)

I require reliable nighttime electricity for my C-PAP machine.

I have a battery back-up and will require reliable electricity during the day to
recharge.
(Check box)

Any other respiratory symptom, condition, or surgery not previously listed for which you
have sought medical attention in the past two years.
(Check box)

(Check box)

I was given a diagnosis for my symptoms.

Diagnosis:
<>

Date of diagnosis:
<>

I do not know the name of the condition causing my symptoms or I have not been
given a diagnosis.
(Check box)

Date of initial symptoms:
<>

How are you currently managing this condition?
Describe:
<>
(Check box)

I require oral medication to control my symptoms.

(Check box)

I require inhaled medication to control my symptoms.

(Check box)

I had surgery due to this condition in the past two years.

Describe:
<>
(Check box)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>

Rheumatology and Immunology
(Diseases caused by an overactive immune system and chronic inflammation)
Have you ever been diagnosed with any of the following conditions?
(Check box)

Select all that apply:

Ankylosing Spondylitis, Systemic Lupus Erythematosus, Polymyositis, Dermatomyositis,
Scleroderma, Psoriatic Arthritis, Fibromyalgia, Chronic Fatigue Syndrome, Rheumatoid Arthritis,
Juvenile Rheumatoid Arthritis Vasculitis, other with <>
Date of diagnosis:
<>
(Check box) I

am currently being treated for this condition.

<>
(Check box) I

have been diagnosed with a rheumatological condition that required the use of
immunosuppressants (including chronic steroids) or injectable drugs.
Describe:
<>

YOU MUST CHECK ONE OF THE STATEMENTS BELOW
the past two years, I have seen a primary care physician, immunologist, or
rheumatologist for any condition cause by chronic inflammation from an overactive immune
system or ailments of the joints such as arthritis or a medication refill (see below for a list of
conditions).
(Check box) I have not seen a doctor in the past two years for any condition caused by chronic
inflammation from an overactive immune system, or ailment of the joints such as arthritis.
(Check box) In

(Check box)

Reactive arthritis (Reiter’s syndrome)

Date of diagnosis:
<>

How are you currently managing this condition?
Describe:
<
(Check box)

I have prescription medication for this condition.

(Check box)

I require a specialist for specialized monitoring and/or follow-up for this condition.

Describe:
<>
(Check box)

Sjogren’s syndrome

Date of diagnosis:
<>

How are you currently managing this condition?
Describe:
<
(Check box)
(Check box)

I have prescription medication for this condition.

I require a specialist for specialized monitoring and/or follow-up for this condition.

Describe:
<>
(Check box) Any rheumatoid or immunologic symptom, diagnosed condition, or surgery not previously
listed for which you have sought medical attention in the past two years.

Diagnosis:
(Check box)

I was given a diagnosis for my symptoms.

Date:
<>

List diagnosis:
<>

I don’t know the name of the condition causing my symptoms or I have not been given
a diagnosis.
(Check box)

Date of initial symptoms:
<>

How are you currently managing this condition?
Describe:
<

(Check box)

I have prescription medication for this condition.

(Check box)

I require a specialist for specialized monitoring and/or follow-up for this condition.

Describe:
<>

UROLOGY AND NEPHROLOGY
(Conditions of the Urinary Tract, Bladder, or Kidney)
In my lifetime, I have had (please choose all that apply):
(CHECK BOX)

Cancer or carcinoma of the urinary tract, bladder, or kidney

Location: <>
Date of diagnosis:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
<>

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX)

Kidney transplant

Date of surgery:
<>

Reason for transplant:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
<>

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX) Nephrectomy

(not for kidney cancer or disease)

Reason for surgery:
Describe:

<>

Date of surgery:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
<>

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX)

Kidney and/or urethral stones

Date of diagnosis:
<>
(CHECK BOX)

I have had this condition more than once in my lifetime.

Date of most recent episode: <>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
<>

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX)

I follow a special diet due to having this condition.

Describe:
<>
(CHECK BOX)

Any other urologic or nephrology surgery (kidneys, ureters, bladder, urethra, or testes)

Type of surgery:
Describe:
<>

Diagnosis:
<>

Date of diagnosis:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECKBOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX)

Solitary or horseshoe kidney

Date of diagnosis:
<>

I have had surgery for this condition.

(CHECK BOX)

Reason for surgery:
Describe:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECKBOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX)

Polycystic kidney disease

Date of diagnosis:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECKBOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX) Glomerulonephritis/nephritis

(inflammation of the kidney)

Date of diagnosis:
<>

Cause of glomerulonephritis/nephritis:
Describe:
<>

Status of condition is:
Acute one-time occurrence
OR
(CHECK BOX) Chronic ongoing condition
(CHECK BOX)

(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECKBOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX)

Renal failure

Date of diagnosis:
<>

Cause of the renal failure:
Describe:
<>

Status of condition is:

Acute one-time occurrence
OR
(CHECK BOX) Chronic ongoing condition
(CHECK BOX)

(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECKBOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX)

Chronic bladder or pelvic pain (interstitial cystitis)

Date of diagnosis:
<>
(CHECK BOX)

I am currently being treated for this condition.

Describe:
<>
(CHECKBOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>

YOU MUST CHECK ONE OF THE STATEMENTS BELOW
In the past two years, I have seen a primary care physician, nephrologist, urologist, or other
doctor for a urinary tract, bladder, or kidney condition or a medication refill (see list of conditions
below).
(CHECK BOX)

I have not seen a doctor in the past two years for any urinary tract, bladder, or kidney
condition.
(CHECK BOX)

Please check all conditions that apply.
(CHECK BOX) Recurrent

cystitis, recurrent pyelonephritis, or other infections of the urinary tract
(recurrent includes two episodes in a six-month period or more than two episodes in the last two
years)
Diagnosis: <>

Date of initial diagnosis:
<>

List number of episodes:
<>

Date of most recent episode:
<>

How are you currently managing this condition?
Describe:
<>

I have prescription medication for this condition.

(CHECK BOX)
(CHECKBOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX)

Diagnosis: Bladder cystocele (weakened, stretched bladder)

Date of diagnosis:
<>

How are you currently managing this condition?
Describe:
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require personal care items (i.e., disposable or durable medical equipment) for this

condition.
Describe:
<>
(CHECKBOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>

(CHECK BOX)

Diagnosis: Stress incontinence (loss of urinary control)

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require personal care items (i.e., disposable or durable medical equipment) for this

condition.
Describe:
<>
(CHECKBOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX) Diagnosis:

Benign prostatic hypertrophy (enlargement of the prostate gland)

Date of diagnosis:
<>

How are you currently managing this condition?
Describe:
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require personal care items (i.e., disposable or durable medical equipment) for this

condition.
Describe:
<>
(CHECKBOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>

(CHECK BOX) Diagnosis:

Any other abnormalities of the genitourinary tract

<> Male

Actual diagnosis: <>
<> Female

Actual diagnosis: <>
Date of diagnosis:
<>

How are you currently managing this condition?
Describe:
<>

I have had this condition more than once in the last two years.

(CHECK BOX)

List number of times:
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECKBOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX) Diagnosis: Genital

Herpes

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:

<>
(CHECK BOX) Diagnosis: Genital

Ulcers

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX) Diagnosis: Genital

Warts

Date of diagnosis:
<>

How are you currently managing this condition?
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>
(CHECK BOX) Diagnosis: Any other kidney, bladder, urinary tract symptoms, or condition of the
genitourinary system not previously listed for which you have sought medical attention in the past
two years.

Diagnosis: <>
(CHECK BOX) Date

of diagnosis:

<>

How are you currently managing this condition?
<>

I have had this condition more than once in the last two years.

(CHECK BOX)

List dates:
<>
(CHECK BOX)

I have prescription medication for this condition.

(CHECK BOX)

I currently require ongoing medical treatment for this condition.

Describe:
<>
(CHECKBOX)

I require a specialist for monitoring and/or follow-up for this condition.

Describe:
<>

CLOSING QUESTIONS
The questions in the section below refer to any conditions that you have not already provided
information.
<>

I have chronic or active condition(s) that are not previously listed or described.

If Yes, Describe:
<>
<>

I have chronic pain that has not been previously listed or described.

If Yes, Describe:
<>
<>

I use medical equipment (either daily or as needed) that has not been previously listed

If Yes,

Select all that apply:
(CHECK BOX)

Insulin pump

(CHECK BOX)

C-PAP machine

(CHECK BOX)

Compressive device

(CHECK BOX)

Wheelchair, cane, walker, crutches

(CHECK BOX)

Hearing aid

(CHECK BOX) Pacemaker
(CHECK BOX) Prosthetic

or defibrillator

device

(CHECK BOX) Other medical equipment

that requires the use of batteries or electricity for

maintenance
Describe: <>
<> Based on a condition (or conditions) I’ve listed in this questionnaire, I

support.
If Yes, Please

describe the support you may need:

<>

believe that I will need special medical