DS-3026 Medical History and Physical Examination Worksheet

U.S. Department of State

MEDICAL HISTORY AND
PHYSICAL EXAMINATION WORKSHEET

OMB No. 1405-0113
EXPIRATION DATE: XX/XX/XXXX
ESTIMATED BURDEN: 15 minutes
(See Page 2 - Back of Form)

Photo
Surnames

Given Names

Birth Date (mm-dd-yyyy) Document Type

Exam Date (mm-dd-yyyy)

Document Number

Case or Alien Number

1. Medical History (Past or present)
No

Yes

No
Applicant appears to be providing unreliable or false
information, specify in remarks
General
Illness or injury requiring hospitalization (including psychiatric)
Cardiology
Hypertension
Congestive heart failure or coronary artery disease
Arrhythmia
Rheumatic heart disease
Congenital heart disease
Pulmonology
Former
Current
Tobacco use:
Asthma
Chronic obstructive pulmonary disease
Tuberculosis history: Diagnosed (mm-yyyy)
Treatment Completed (mm-yyyy)
Fever
Cough
Night sweats
Weight loss
Psychiatry
Psychological/Psychiatric Disorder (including major depression,
bipolar disorder, or schizophrenia)
Major impairment in learning, intelligence, self-care, memory, or
communication
Use of substances other than those required for medical reasons
Substance use or substance induced disorders of substances on
the Controlled Substances Act (CSA)
Substance use or substance induced disorders of substances not
on the CSA (including alcohol)
Ever caused serious injury to others, caused major property
damage or had trouble with the law because of medical condition,
mental disorder, or influence of alcohol or drugs
Ever had thoughts of harming yourself
Ever acted on those thoughts
Ever had thoughts of harming others
Ever acted on those thoughts

Yes
Obstetrics
Pregnancy, current
Estimated delivery date (mm-dd-yyyy)
LMP
Previous live births, number:
Birth dates of live births (mm-dd-yyyy)

Sexually Transmitted Diseases
Previous treatment for sexually transmitted diseases,
specify date (mm-yyyy) and treatment:
Syphilis
Gonorrhea
Endocrinology
Diabetes
Thyroid disease
Hematologic/Lymphatic
Anemia
Sickle Cell Disease
Thalassemia
Other hemoglobinopathy
Other
An abnormal or reactive HIV blood test
Diagnosed (mm-yyyy)
Malignancy, specify:
Kidney or Bladder disease
Chronic liver disease (including hepatitis B or C)
Previous treatment for Hansen's Disease
Treatment Completed (mm-yyyy)
Other medical conditions requiring treatment, specify:

Disabilities (including loss of arms or legs), specify:
Neurology
History of stroke
Seizure disorder
2. Current Medications (List all current medications)

DS-3026
05-2017

3. Previous Surgeries (List all previous surgeries)

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4. Vital Signs and Vision
Height

cm

BP

Weight

kg

Pulse

BMI

/

Temperature

°C

Visual acuity at 6 meters:

/ min
Respiratory
Rate

kg/m²

/ min

Uncorrected L 6/

R 6/

Corrected

R 6/

L 6/

5. Physical Examination (include all findings and give details in Remarks)
N, normal; A, abnormal
N

A

N

A

General appearance
Nutritional status (including acute wasting and or chronic stunting
malnutrition)
Hearing and ears
Eyes
Nose, mouth, and throat (include dental)
Heart (S1, S2, murmur, rub)
Lungs
Abdomen (including liver, spleen)
Lymph nodes

Musculoskeletal system (including gait)
Extremities (including pulses, edema)
Skin
Hematologic
Nervous system: Sequelae of stroke or cerebral palsy, other
neurologic disabilities
Mental status (including mood, intelligence, perception, thought
processes, and behavior during examination)
Fundal height (if applicable):

6. Mental Health Specialist
Referral made to mental health specialist. If so, attach report.
Any physical or mental disorder (excluding addiction or abuse of specific substance on the Controlled Substances Act but including other substance-related
disorder)
Class A, with harmful behavior, list disorder(s)
Class B, without harmful behavior, list disorder(s)
Addiction or abuse of a specific substance on the Controlled Substances Act
Class A, list substance(s)
Class B, in remission, list substance(s)
7. Syphilis Laboratory Results and Treatment
Laboratory testing not done
Test Name

Date specimen reported
(mm-dd-yyyy)

Reactive

Nonreactive

Titer

Screening
Confirmatory
Treated

If treated, therapy:

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

Yes

Benzathine penicillin, 2.4 MU IM

No

Other (therapy, dose):
Treated by panel physician:

Yes

No

Stage of syphilis (mark one):
Primary

Tertiary

Secondary

Neurosyphilis

Early latent

Congenital

Late latent or latent of
unknown duration
8. Gonorrhea Laboratory Results and Treatment
Laboratory testing not done

Test Name

Date speciman reported
(mm-dd-yyyy)

Positive

Negative

Screening
Drug

DS-3026

Dosage

Start Date (mm-dd-yyyy)

End Date (mm-dd-yyyy)

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9. Diagnosis and Treatment for Hansen's Disease
Complete this section only if the applicant was diagnosed by the panel physician or was on Hansen's Disease treatment at the time of presentation for their
medical examination
Type of Hansen's Disease
Treatment
Multibacillary

Partial (> 7 days)

Paucibacillary

Completed

Drug

Dosage

Start Date (mm-dd-yyyy)

End Date (mm-dd-yyyy)

Treated by panel physician
Yes
No
If not treated by panel physician, was referral made by panel physician to another provider for treatment:
Yes. Provide facility name:
No
Diagnosis
Initial diagnosis made by panel physician
Initial diagnosis made by non-panel physician before medical evaluation by panel physician
If so, year of diagnosis:
10. Remarks

PAPERWORK REDUCTION ACT AND CONFIDENTIALITY STATEMENTS
PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time required for searching existing
data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do
not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this
burden estimate and/or recommendations for reducing it, please send them to: [email protected]
CONFIDENTIALITY STATEMENT
INA Section 222(f) provides that visa issuance and refusal records shall be considered confidential and shall be used only for the formulation,
amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. The U.S. Department of State uses the
information provided on this form to determine an individual's eligibility for a U.S. visa. Certified copies of visa records may be made available to a
court which certifies that the information contained in such records is needed in a case pending before the court. The information provided may also be
released to federal agencies for law enforcement, counterterrorism and homeland security purposes; to Congress and courts within their sphere of
jurisdiction; and to other federal agencies who may need the information to administer or enforce U.S. laws. Although furnishing this information is
voluntary, individuals who fail to submit this form or who do not provide all the requested information may be denied a U.S. visa or experience
processing delays.
DS-3026

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