Form DS-6561 Pre-Assignment for Overseas Duty

OMB APPROVAL NO. 1405-0194
EXPIRATION DATE 07/31/2020
ESTIMATED BURDEN: 1 HOUR*

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

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

DATE OF EXAM (mm-dd-yyyy)

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

5. Sex
Male

6. Place of Birth (for Employee and all Eligible Family Members)

Female

7. SSN of Employee (for Employee only)

8. Status
Employee

Spouse

Dependent Child

Civil Service

WAE

PSC Contractor / Bureau or Office:

Locally Engaged Staff

DOD Civilian

DOD Contractor

Domestic Partner

9. EMPLOYMENT STATUS:

Contractor (include name of contracting company and assoc. USG Agency):
LNA

Other:

10. Post of Assignment and Estimated Dates of Arrival / Departure
(if known)

11. Details of Assignment (Check all that apply)
Frequent TDY
Iraq

a. Proposed Post:

EDA
(mm-dd-yyyy)

AFG
Other ESCAPE Post/Name:

b. Present Post:

Other:

EDD
(mm-dd-yyyy)

12. Email Address of examinee or parent of child < 18 y/o
(Where you can be reached for the next 90 days)

13. Telephone number of examinee or parent of child < 18 y/o
(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
07-2017

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Name of Examinee

DOB

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

Do you (or your child) have a hisory of:

Yes

No

(parents - please answer for children < 18 years of age)
Yes No

21. Rheumatologic disorder?
22. Anemia?

1. Frequent/severe headaches or migraines?

23. Blood transfusion?

2. Fainting or dizzy episodes?

24. Malaria or other tropical disease?

3. Stroke, TIA or head injury?

25. Any skin or nail disorder?

4. Epilepsy, seizures or other neurologic disorders?

26. Cancer of any type?

5. Chronic eye or vision problems?

27. Any thickening or lump in breast, testicle?

6. Ear, nose, throat problems; hearing loss, hoarseness?
7. Allergies or history of anaphylactic reaction?
8. Shortness of breath, asthma, or COPD?
9. History of abnormal chest x-ray?
10. History of positive TB skin test or tuberculosis?
11. Aneurysm, blood clot or pulmonary embolism?
12. High blood pressure?
13. Heart problems, murmur or palpitations?
14. Have you smoked any cigarettes in the last month?
15. Stomach, esophageal, intestinal problems?
16. Jaundice or hepatitis (type)?
17. Intestinal, rectal problems or hernia?
18. Urinary or kidney problems, blood in urine?
19. Diabetes or thyroid disorder?
20. Joint or back pain/injury?

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)
29. Have you used marijuana, amphetamines, narcotics,
cocaine, or hallucinogenic drugs?
30.Have you been in psychotherapy/counseling or been
prescribed medication for depression, anxiety, mood or stress?
31. Have you felt unusually depressed, sad, blue, or had
frequent crying spells which lasted more than two weeks at a time?
32. Have you had frequent or recurrent episodes of:
difficulty in relaxing or calming down, panicky feelings, irritability, anger,
feeling hyper, or nervousness?
33. Have you experienced any emotional or physical
symptoms related to a past trauma?

Yes
No
Children Only:
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)
35. Date of last PAP test?
Results:
36. Date of last Mammogram?
Results:
Yes
No Are you pregnant? Est. due date:

Men/Women: Colon Cancer Screening:
(provide results if applicable, N/A if not applicable)
38. Date of last colon cancer screening, if applicable:
Test (colonoscopy/sigmoidoscopy/guiacFOBT):
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 OF 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)
Date (mm-dd-yyyy)

Illness or Operation

Name of Hospital

City and State

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.
V. SIGNATURE OF EXAMINEE OR PARENT OF CHILD <18 Y/O (I certify I have read and understand the above statement.)
Date (mm-dd-yyyy)

DS-6561

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Name of Examinee

DOB

V. INSTRUCTIONS FOR COMPLETION AND SUMBISSION OF FORM 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: Newborn exam cannot be accepted if completed before four (4) weeks of age
1. Height

2. Weight

3. BMI

in. or

lbs. or

cm.

kgs

VII. Clinical Evaluation
Check each item as indicated.
Check "NE" if not evaluated.

4. Pulse

Normal Abnormal

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

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/abnormalities)
10. Abdomen
11. Male Genitalia
12. Anus/Rectum/Prostate (if indicated)
13. Musculoskeletal / Spine / Extremities
(Note limitations)
14. Lymph Nodes
15. Neurologic
16. Female Gynecologic (if indicated)
DS-6561

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Name of Examinee

DOB

IX. LABORATORY ANALYSIS: All tests are required unless otherwise specified. Test results from previous 12 months are acceptable.
COPIES OF LABORATORY REPORTS MUST BE SUBMITTED FOR REVIEW AND MUST BE IN ENGLISH
1. Hematology:
1a. Hematology :
2. Chemistry
3. Serology
Ages 1 year to 11 years
Ages 12 years and older
Ages 12 years and older
Ages 12 years and older
Hematocrit
or
Hemoglobin

%
gms%

Hematocrit
or
Hemoglobin
WBC

%

Fasting Blood Sugar

gms%

HgA1C (if indicated)

HIV I/II Antibody

/cmm Creatinine

Platelets
ALT
4. Tuberculin Skin Test: Required for ages 1 and over (unless previously positive)
Results:
mm of induration
Date:
Interferon Gamma Release Assay: (may substitute for TST if > 5 y/o or
In those with previous BCG)
Results:

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

Date:

• Required for those with > 10 mm TST newly identified
or if positive IGRA
OR
• When clinically indicated
6. ECG (50 years or older, earlier if indicated) - submit tracing

If no TB screening performed, explain why:

Results:

Previous active tuberculosis

Yes

No

Date:

Previous positive TST or IGRA

Yes

No

Date:

Previous LTBI treatment

Yes

No

Date:

Hx of BcG vaccine

Yes

No

Date:

Date:

Results:
Date:

Other:
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

8. G6PD (If not previously documented) for malarial prophylaxis

(Rh) Dµ:

(weak D):

Results:

Date:

9. Blood lead level (recommended screening ages 12 months to 5 years)
X. Assessment or Problem List

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

Typed Name of Examiner

Signature of Examiner

Examining Facility

Telephone Number

Date (mm-dd-yyyy)

Address

DS-6561

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