Form DS-6561 Pre-Assignment for Overseas Duty

U.S Department of State
Bureau of Medical Services, M/MED, Room L101, SA-1, Washington, DC 20522- 0102

OMB APPROVAL NO. xxxx
EXPIRATIONDATE: XX/XX/XXXX
ESTIMATED BURDEN: 1 hour*

OVERSEAS PRE-ASSIGNMENT MEDICAL HISTORY AND EXAMINATION
Non-Foreign Service Personnel and Their Family Members
PRIVACY ACT STATEMENT
AUTHORITIES: The information is sought pursuant to the Foreign Service Act of 1980, as amended (Title 22 U.S.C.4084).
PURPOSE: The information solicited on this form will be used to make appropriate medical clearance decisions.
ROUTINE USES: Unless otherwise protected by law, the information solicited on this form may be made available to appropriate agencies, whether Federal, state, local,
or foreign, for law enforcement and other authorized purposes. The information may also be disclosed pursuant to court order. More information on routine uses can be
found in the System of Records Notice State-24, Medical Records.
DISCLOSURE: Providing this information is voluntary; however, not providing requested information may result in the failure of the individual to obtain the requisite
medical clearance pursuant to 16 FAM 211.
PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average one (1) hour per response, including time
required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final
collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this
burden estimate and /or recommendation for reducing it, please send them to: M/MED/EX, Room L101 SA-1, U.S. Department of state, Washington, DC 20522

I. DEMOGRAPHIC INFORMATION
TO BE FILLED OUT BY EXAMINEE (OR PARENT for EXAMINEE < 18 y/o)

DATE OF EXAM: (mm-dd-yyyy)

1. Name of Examinee: (Last, First, MI)

2. If Eligible Family Member, Name of Employee:

3. U.S. Govt. Agency and Branch:

4. Date of Birth: (mm-dd-yyyy)

6. Status:

⧠ Employee

⧠ Spouse

⧠ Dependent Child

5. Sex:

⧠ Female
⧠ Male

⧠ Domestic Partner

7. EMPLOYMENT STATUS:
⧠ Civil Service
⧠ WAE
⧠ PSC Contractor / Bureau or Office: ___________________
⧠ Locally Engaged Staff
⧠ DOD Civilian
⧠ DOD Contractor
⧠ Contractor (include name of contracting company and assoc. USG Agency): ___________________________________
8. Post of Assignment Estimated Dates of Arrival/ Departure
(if known)
a. Proposed Post(s): ______________________________
EDA: __________________(mm-dd-yyyy)
b. Present Post: _______________________________
EDD: ____________________(mm-dd-yyyy)

9. Details of Assignment: (please check all that apply)
⧠ Frequent TDY
⧠ Iraq
⧠ AFG
⧠ Other ESCAPE Post/Name ______________
⧠ Other: ______________________________
______________________________
______________________________

10. Email Address of examinee or parent of child < 18 y/o:

11. Telephone number: (patient or dependent > 18 years of age):

(Where you can be reached for the next 90 days):

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

To the individual and/or health care provider completing the medical history review /exam: The Genetic Information
Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring
genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with
this law we are asking that you NOT provide any genetic information when responding to this request for medical information.
‘Genetic Information’ as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family
members’ genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic
information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family
member receiving assistive reproductive services.
DS-6561
XX- 20XX_

page 1 of 4

NAME OF EXAMINEE:

DOB:

II. MEDICAL HISTORY
PLEASE ANSWER THE FOLLOWING QUESTIONS: For YES answers, provide a brief explanation, attach additional pages if needed.

Do you (or your child) have a history of:
(parents - please answer for children < 18 years of age)
⧠ Yes ⧠ No 1. Frequent/severe headaches or migraines?
⧠ Yes ⧠ No 2. Fainting or dizzy episodes?
⧠ Yes ⧠ No 3. Stroke, TIA or head injury?
⧠ Yes ⧠ No 4. Epilepsy, seizures or other neurologic disorders?
⧠ Yes ⧠ No 5. Chronic eye or vision problems?
⧠ Yes ⧠ No 6. Ear, nose, throat problems; hearing loss, hoarseness?
⧠ Yes ⧠ No 7. Allergies or history of anaphylactic reaction?
⧠ Yes ⧠ No 8. Shortness of breath, asthma, or COPD?
⧠ Yes ⧠ No 9. History of abnormal chest x-ray?
⧠ Yes ⧠ No 10. History of positive TB skin test or tuberculosis?
⧠ Yes ⧠ No 11. Aneurysm, blood clot or pulmonary embolism?
⧠ Yes ⧠ No 12. High blood pressure?
⧠ Yes ⧠ No 13. Heart problems, murmur or palpitations?
⧠ Yes ⧠ No 14. Have you smoked any cigarettes in the last month?
⧠ Yes ⧠ No 15. Stomach, esophageal, intestinal problems?
⧠ Yes ⧠ No 16. Jaundice or hepatitis (type)?
⧠ Yes ⧠ No 17. Intestinal, rectal problems or hernia?
⧠ Yes ⧠ No 18. Urinary or kidney problems, blood in urine?
⧠ Yes ⧠ No 19. Diabetes or thyroid disorder?
⧠ Yes ⧠ No 20. Joint or back pain/injury?

⧠ Yes ⧠ No
⧠ Yes ⧠ No
⧠ Yes ⧠ No
⧠ Yes ⧠ No
⧠ Yes ⧠ No
⧠ Yes ⧠ No
⧠ Yes ⧠ No

21. Rheumatologic disorder?
22. Anemia?
23. Blood transfusion?
24. Malaria or other tropical disease?
25. Any skin or nail disorder?
26. Cancer of any type?
27. Any thickening or lump in breast, testicle?

⧠ Yes ⧠ No 28. Have you consumed at any one time in the past year,
more than 5 alcohol drinks for males or 4 drinks for females? Explain.
IN THE PAST SEVEN (7) YEARS (for questions 29-33)
(parents - please answer for children < 18 years of age)
⧠ Yes ⧠ No 29. Have you used marijuana, amphetamines, narcotics,
cocaine, or hallucinogenic drugs?
⧠ Yes ⧠ No 30.Have you been in psychotherapy/counseling or been
prescribed medication for depression, anxiety, mood or stress?
⧠ Yes ⧠ No 31. Have you felt unusually depressed, sad, blue, or had
frequent crying spells which lasted more than two weeks at a time?
⧠ Yes ⧠ No 32. Have you had frequent or recurrent episodes of:
difficulty in relaxing or calming down, panicky feelings, irritability,
anger, feeling hyper, or nervousness?
⧠ Yes ⧠ No 33. Have you experienced any emotional or physical
symptoms related to a past trauma?

Children Only ⧠ Yes ⧠ No

34. Has your child been referred for any current or potential special educational services, accommodations, or
modifications (i.e.: IFSP, Early Intervention, IEP, 504 Plan)? Explain:
Women: (provide results if applicable, N/A if not applicable)
Men/Women: Colon Cancer Screening:
35. Date of last PAP test? _______________Results:_______________
38. Date of last colon cancer screening? If applicable _____________
36. Date of last Mammogram? _____________Results: ____________
Test (colonoscopy/sigmoidoscopy/guiacFOBT):___________________
⧠ Yes ⧠ No 37. Are you pregnant? Est. due date: _________________
Results: __________________________________________________
For all applicants, employees or eligible family members:
39. Is there any other medical or mental health condition not covered in questions 1 – 38? ⧠ Yes ⧠ No Explain:

IIA: Explanations required for “yes” answers to questions 1 – 39. Attach Additional sheets as needed.

III. List Current Medications (include prescription, over the counter, vitamins and herbs)

Drug or Other Allergies

_________________________

_________________________

_________________________

_________________________

_________________________
_________________________

_________________________
_________________________

_________________________
_________________________

_________________________
_________________________

IV. Hospitalizations / Operations / Medical Evacuations: (Include all medical and psychiatric illnesses/hospitalizations)
Date (mm-dd-yyyy)

Illness, Operation, Medevac

Name of Hospital

City and State, Country

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

__________________________

Any knowing and willful omission, falsification, or fraudulent statement regarding material medical information may constitute a criminal offense under 18 U.S.C.
§ 1001, and individuals committing such an offense may be subject to criminal prosecution. Employees of the United States Government also may be subject to
disciplinary action, up to and including separation, for any knowing and willing omission or falsification or fraudulent statement of material information.

Signature of Examinee/ (Parent for children under age 18) (I certify that I have read and I understand the above statements
Date: (mm-dd-yyyy)
DS – 6561
XX-20XX

Page 2 of 4

NAME OF EXAMINEE:

DOB:

V. INSTRUCTIONS FOR COMPLETION AND SUBMISSION OF DS-6561:
MEDICAL EXAMINER



Medical Examiner must comment on positive history on page 2. Medical Examiner must comment on physical findings and
provide recommendations for treatment/further study/consultations of medical & mental health problems.
Medical Examiner must sign on page 4.

EXAMINEE / SPONSOR / PARENT





All fields on page 1 and 2 must be filled out. Examinee or parent/employee sponsor must sign on page 2.
Submit copies of all laboratory tests and additional medical reports with DS-6561.
All Lab tests and medical reports must be in English, and identified with full name and date of birth of examinee.
Keep originals as a permanent record. Do NOT submit by U.S. Mail or by courier service (e.g. FedEx or DHL).
The preferred method to submit the DS – 6561 (and supporting documentation) is to scan and email in PDF format to:
[email protected]. If it is not possible to scan, please fax to Medical Records department FAX: 703-875-4850
If you wish to confirm that your exam forms were received, please email [email protected].

VI: Medical Examiner comments on significant patient medical history and items checked “yes” on page 2/section II.
Use additional pages if needed.

VII: CLINICAL EVALUATION (FOR NEWBORN EXAM, INFANT MUST BE FOUR (4) WEEKS OF AGE OR OLDER)
1.

Height

2.

Weight

________ Inches or

________ Lbs. or

________ cm.

________ Kgs

3. BMI

VIII. PHYSICAL EXAM
Check each item as indicated. Check “NE” if not evaluated.

4. Pulse

5. Blood Pressure (sitting): If above 140/85 repeat 3 times at
visit and record:

Normal

Abnormal

NE

Notes
(Describe every abnormality in detail.
Include pertinent item number before each comment.)

1. General/Constitution
2. Mental / Affect / Mood / Development (children)
3. Skin
4. Eye
5. Ears/Nose/Throat
6. Neck/Thyroid
7. Lungs/Thorax
8. Breasts
9. Cardiovascular (record murmurs or abnormalities)
10. Abdomen
11. Genitalia ( male – note hernia or masses)
12. Anus/Rectum/Prostate (if indicated)
13. Musculoskeletal, spine and extremities (note limitations)
14. Lymph nodes
15. Neurologic
16. Female (pelvic exam if indicated)
DS – 6561
XX-20XX

Page 3 of 4

NAME OF EXAMINEE:

DOB:

IX. LABORATORY ANALYSIS
All tests are required unless otherwise specified. Results from previous 12 months are acceptable.
COPIES OF LABORATORY REPORTS MUST BE SUBMITTED FOR REVIEW AND MUST BE IN ENGLISH
1a. Hematology Tests: Ages 1 year to 11 years
Hematocrit ____________%
Or
Hemoglobin____________gms%

2.

Chemistry (ages 12 and older)

Fasting Blood sugar _______

1b. Hematology Tests: Ages 12 years and older
Hematocrit ____________%
Or
Hemoglobin____________gms%
WBC ________________/cmm
Platelets __________________

HIV I/II antibody ________________

Creatinine ____________
ALT ___________________

Date:___________

5. Chest X Ray: (PA and lateral) - submit report


Interferon Gamma Release Assay: (may substitute for TST if > 5 y/o or
In those with previous BCG) Results: _______________Date:______________
If no TB screening performed, explain why:
Previous active tuberculosis

Serology (ages 12 and older)

HgA1C (if indicated) _______

4. Tuberculin Skin Test: Required for ages 1 and over (unless
previously positive)
Results: ________________ mm of induration

3.

⧠ Yes _____ ⧠ No _____ Date: ________



Required for those with > 10 mm TST newly identified or if
positive IGRA
OR
When clinically indicated
Results: __________________________
Date: __________________________

Previous positive TST or IGRA ⧠ Yes _____ ⧠ No _____ Date: ________
Previous LTBI treatment

⧠ Yes _____ ⧠ No _____ Date: ________

Hx of BcG vaccine

⧠ Yes _____ ⧠ No _____ Date: ________

Other: __________________________________________

6. ECG (50 years or older, earlier if indicated) submit tracing
Results: __________________________
Date: __________________________

OPTIONAL TESTS: The following tests may be performed at the discretion of the Examiner, with patient consent. They are not required for a medical
clearance determination. If performed, results may be used in the provision of care to individuals covered under the Department of State Medical Program.
7. Blood Type: ( if not previously documented) Type: ABO___________ (Rh) Dµ: ____________ (weak D): ___________________
8. G6PD: (If not previously documented) for malarial prophylaxis
Results :_______________ Date: _____________________
9. Blood lead level: (recommended screening ages 12 months to 5 years) Results :_______________ Date: _____________________

X. Assessment or Problem List

XI. Recommendation for Treatment / Further Study /
Consultation or Follow - Up

Typed Name of Examiner

Signature of Examiner

Examining Facility
Address

Telephone Number

DS – 6561
XX-20XX

Date (mm-dd-yyyy)

Page 4 of 4