Form DS-1622 Medical History and Examination for Children Age 11 and

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

MEDICAL HISTORY AND EXAMINATION

*OMB APPROVAL NO. 1405-0068
EXPIRATION DATE: XX-XX-20XX
ESTIMATED BURDEN: 1 HOUR

FOR CHILDREN AGE 11 AND YOUNGER
PRIVACY ACT NOTICE
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 from this form will assist in making a medical clearance decision for individuals eligible to participate in
the Department of State Medical Program while assigned abroad. (16 FAM 100 - 200)
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 EMPLOYEE/SPONSOR OR PARENT
1. Name of Examinee (Last, First, MI)

2. Date of Birth (mm-dd-yyyy)

3. Sex
Female

Male
4. Full Name of Employee/Applicant/Sponsor

5. MED Number if known (Child examinee)

6. Place of Birth
State

City

Country

7. Agency of Employee/Applicant/Sponsor
STATE

USAID

FCS

Non-Foreign Service Agency
8. E-mail Address of Parent/Sponsor
(Where You can be Reached for the Next 90 days)

FAS

U.S. Agency for Global Media

DoD Civilian

DoD Contractor

Contracting Company
9. Purpose of Exam
New Dependent (pre-employment, newborn, adoption)

Primary:

In-Service Exam

Alternate:
Separation
10. Telephone Number of Parent/Sponsor
(Where You can be Reached for the Next 90 days)

11. Post of Assignment and Estimated Dates of Arrival / Departure
a. Proposed Post

EDA
(mm-dd-yyyy)

Primary:
Alternate:

b. Present Post

EDD
(mm-dd-yyyy)

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-1622
06-2020

Page 1 of 4

Name of Examinee

DOB

II. MEDICAL HISTORY
ANSWER THE FOLLOWING QUESTIONS: ALL YES ANSWERS MUST HAVE A WRITTEN EXPLANATION WITH DATE OF OCCURENCE IN BOX IIA.

Does your child currently, or have a hisory of:
Yes

Yes

No
20. Joint, tendon or any orthopedic disorder?

No
1. Frequent/severe headaches?

21. Rheumatologic or immune disorder?

2. Fainting, dizzy episodes, or syncope?

22. Malaria, tropical or other infectious disease?

3. Seizures or neurologic disorders?

23. Any recent unexpected weight loss/gain?

4. Eye or vision problems?

24. Any skin or nail disorder

5. Ear, nose, or throat problems, including hearing loss?

25. History of positive TB skin test, IGRA, or Tuberculosis?

6. Allergies or history of anaphylactic reaction?
7. Cough, wheeze, shortness of breath, asthma?
8. Murmurs, palpitations, or other heart problems?
9. Rheumatic fever?
10. Diabetes, thyroid, or other endocrine disorders?
11. Hormonal or metabolic disorder?
12. Stomach, esophageal, or other intestinal problems?
13. Jaundice, hepatitis, gallbladder or other liver disease?
14. Intestinal, rectal problems or hernia?
15. Anemia?
16. Blood transfusions?
17. Urinary or kidney problems, blood in urine?
18. Cancer of any type?
19. Premature birth, pre or post-natal complications?

Yes

No
25. Has your child been referred for any current or potential
special educational services, accommodations, or
modifications (i.e.: IFSP, Early Intervention, IEP, 504
Plan)?
26. In the past seven years, has your child been in
psychotherapy/counseling or been prescribed medication
to help with depression, anxiety, mood or stress?
27. Has your child felt unusually depressed, sad, blue, or
had frequent crying spells which lasted more than 2 weeks
at a time, within the past seven years?
28. In the past seven years, has your child had frequent or
recurrent episodes of: difficulty relaxing or calming down,
panicky feelings, irritability, anger, feeling hyper, or
nervousness?
29. In the past seven years, has your child experienced any
emotional or physical symptoms related to a past trauma?

30. Is there anything else you would like to add about your child's health or well being that was not addressed in questions 1-29?

Yes

No

II a. Explanation required for "yes" answers to questions 1-30. Attach additional sheets as needed

III. LIST OF CURRENT MEDICATIONS (Include prescription, over the counter, vitamins, and herbs)

IV. HOSPITALIZATIONS/OPERATIONS/MEDICAL EVACUATIONS (Include all medical and psychiatric illnesses)
Illness or Operation
Date (mm-dd-yyyy)
Name of Hospital

Drug Or Other Allergies

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 PARENT OR SPONSOR (I certify I have read and understand the above statement.)
Date (mm-dd-yyyy)

DS-1622

Page 2 of 4

Name of Examinee

DOB

VI. INSTRUCTIONS FOR COMPLETION AND SUBMISSION OF DS-1622
MEDICAL EXAMINER
• Medical Examiner must comment on positive history (pg. 2), abnormal physical findings (pg. 3), and provide follow-up recommendations (pg. 4).
• Medical Examiner must sign on page 4.
EMPLOYEE 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-1622.
• 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).
Submit the DS-1622 and other documentation via email in PDF format to [email protected] (preferred), or by fax to the Medical Records Department
at 202-647-0292. If you wish to confirm that your exam forms were received, email [email protected].
VII. Medical Examiner comments on significant patient medical history and items checked "yes" on page 2 / section II. Use additional pages
if needed.

VIII. CLINICAL EVALUATION: Newborn exam cannot be accepted if completed before four (4) weeks of age
1. Height/Length

2. Weight
in. or

lb. or

4. Blood Pressure (age 3 and Over)

kg.

cm.
percentile
5. Head Circumference
(18 months and under)

3.Pulse or HR (REQUIRED FOR ALL AGES
and NEWBORNS) RECORD

percentile
6. Development Appropriate for Age

Yes

No

If NO, attach Development Screen and explain below with detail in assessment / plan
in. or

7. Gestational age at birth

cm.
percentile 8. Immunizations Reviewed
Immunizations current?
IX. PHYSICAL EXAM
Check each item as indicated.
Check "NE" if not evaluated.

Normal Abnormal

NE

Yes

No

Yes

No

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

1. General/Constitution
2. Development
3. Skin
4. Eyes
5. Ears/Nose/Throat
6. Neck/Thyroid
7. Lungs/Thorax
8. Cardivascular
(Record murmurs/abnormalities)
9. Abdomen
10. Genitalia
11. Anus/Rectum
12. Musculoskeletal/Spine/
Extremities (Note limitations)
13. Lymph nodes
14. Neurologic
DS-1622

Page 3 of 4

Name of Examinee

DOB

X. LABORATORY ANALYSIS
NO LABORATORY TESTS REQUIRED FOR INFANTS
For ages 1 year and above, 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
1. Hematology (age 1 and over)
%

Hematocrit

OR

Hemoglobin

gms%

2. Tuberculin Skin Test : REQUIRED for ages 1 and over (unless previously positive) 3. Chest X Ray (PA and lateral) - Required only if TST >
For baseline status in a child who will live overseas in a likely endemic TB area.
10mm, positive IGRA or clinically indicated.
TST Results:

mm of induration

Date:
Results:

IGRA Results:
Date:
Interferon Gamma Release Array: (may substitute for TST if > 5 y/o or
In those with previous BCG)
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:

OPTIONAL TESTS: The following test are not required for a medical clearance determination. The expense of performing these exams is not routinely
authorized. The tests may be performed at the clinical discretion of the examiner with patient consent. If performed or previous results are available,
the results may be used by the Department of State in a medical clearance determination and future clinical care of individuals covered under the
Department's Medical Program.
4. Blood Type ( if not previously documented)

Type: ABO

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

(Rh) Dµ:

(weak D):

Results:

Date:

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

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

NOTICE: This form is not complete until all laboratory tests and results from section X are attached and included with this DS-1622 form.
Typed Name of Examiner

Signature of Examiner

Address

Telephone Number

DS-1622

Date (mm-dd-yyyy)

Page 4 of 4