JF1830 form editing

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"CUI//SP-HLTH when filled in"
Form Approved
O.M.B.
No. 2700-0170
Expires: xx/xx/xxxx

JSC FORM 1830 - REPORT OF MEDICAL EXAMINATION
Applicant Must Complete This Page
PLEASE TYPE OR PRINT CLEARLY IN DARK INK
1. Application For:

2. Last Name

First Name

3. E-mail

Middle Name

Telephone:
Work:

4. Street Address

Other:

City

5. DOB(M/D/Y) 6. Sex

7. Hair Color

State

8. Eyes Color 9. Type:
NASA :
Federal Employee
Commercial Other

Zip

10. Employer:

11. Do you Currently Use Any Medication (Prescription or Nonprescription)?
Yes
No
If yes, give name, purpose, dosage, and frequency.
12. Medical History Have you ever had or do you now have any of the following? Answer “yes” for every condition you have ever had in your
life. Describe the condition and the approximate date of occurrence in the explanation box provided below.
Yes

No

Condition

Yes

No

Condition

Yes

No

Condition

a.

Frequent or severe headaches

i.

Stomach, liver, or intestinal trouble

q.

Motion sickness
requiring medication

b.

Dizziness or fainting spell

j.

Kidney stone or blood in urine

r.

Military medical discharge

c.

Unconsciousness for any reason

k.

Diabetes

s.

Medical rejection by military
service

d.

Eye or vision trouble
(except glasses)

l.

Neurological disorders; epliepsy,
seizures, stroke, paralysis, etc.

t.

Rejection for life or health
insurance

e.

Hay fever or allergy

m.

Mental disorders of any sort depression,
u.
anxiety, etc.

Admission to hospital

f.

Asthma or lung disease

n.

Substance dependence or failed a drug
test (ever), or substance abuse or use
v.
of illegal substance in the last five years

Other illness, disability, or
surgery

g.

Heart or vascular trouble

o.

Alcohol dependence or abuse

h.

High or low blood pressure

p.

Suicide attempt

12 A. Explanations: If you answered YES to any of the above items, describe the condition and the approximate date of occurrence. Use additional page
if needed.

13. Visits to Health Professional Within Last 3 Years.
Date

Yes (explain below)

Name, Address, and Type of Health Professional Consulted

No
Reason For Visit

NOTE: I declare under penalty of perjury that I have examined all the information on this form, and on the accompanying physician form, and it is true
and correct to the best of my knowledge. I understand that anyone who knowingly gives a false statement about a material fact in this information, or
causes someone else to do so, commits a crime and may be subject to a fine or imprisonment.
14. Signature of Applicant

JSC Form 1830  

15. Date

1556
Page 1 of 3

"CUI//SP-HLTH when filled in"
Examiner Must Complete and Sign This Page
Please Type or Print Clearly In Dark Ink
CHECK EACH ITEM IN APPR. COLUMN

Normal

Abnormal

16. Head, face, neck, and scalp

CHECK EACH ITEM IN APPR. COLUMN

Normal

17. Nose

28. Vascular system (Pulse, amplitude and
character, arms, legs, others)
29. Abdomen and viscera (Including hernia)

18. Sinuses
19. Mouth and throat

30. Anus (Not including digital examination)
31. Skin

20. Ears, general (internal and external canals:
Hearing under item 49)
21. Ear Drums (Perforation)

32. G-U system (Not including pelvic
examination)
33. Upper and lower extremities (Strength
and range of motion)

22. Eyes, general (Vision under items 50 to 54)
23. Ophthalmoscopic
24. Pupils (Equality and reaction)

34. Spine, other musculoskeletal
35. Identifying body marks, scars, tattoos
(Size & location)
36. Lymphatics

25. Ocular motility (Associated parallel
movement, nystagmus)
26. Lungs and chest (Not including breasts
examination)

37. Neurologic (Tendon reflexes, equilibrium,
senses, cranial nerves, coordination, etc.)
38. Psychiatric (Appearance, behavior, mood,
communication, and memory)

Abnormal

27. Heart (Precordial activity, rhythm, sounds,
39. General systemic
and murmurs)
NOTES: Describe any above items checked “Abnormal” in detail. Enter item number before each comment. Use additional sheets if necessary.

40. Height

41. Weight

42. Hearing

Voice Test
Right Ear Left Ear

Audiometer Threshold in Decibels
Right Ear
Left Ear
500

43. Distant Vision
Right
20/
Left
20/
Both
20/
46. Field of Vision
Normal
Abnormal

3000

44. Near Vision
Corrected
Right
20/
Corrected to 20/
Corrected
Left
20/
Corrected to 20/
Corrected
Both
20/
Corrected to 20/
47. Heterophoria 20’ (in prism diopters)
Esophoria
Exophoria

48. Blood Pressure (sitting mm of Mercury)
Systolic

1000 2000

Diastolic

49. Pulse
(Resting)

50. Urinalysis

Normal

Albumin

4000

500

1000

2000

3000

4000

45. Color Vision
Normal
Abnormal
Right Hyperphoria

Abnormal (give results)
Sugar

52. Other Tests Given

Left Hyperphoria

51. EKG (Date)
MM

DD

YY

EKG Results:

53. Significant Medical History
Yes
No
Abnormal Physical Findings
Yes
No
Physician shall elaborate on all pertinent data; comment on all "YES" answers in the Medical History (pg 1, #12) and any abnormal findings of the
exam. Physician may develop, by interview, any additional medical history deemed important, and record any significant findings here. ATTACH
ADDITIONAL COMMENTS ON HISTORY & FINDINGS.

54. Applicant’s Name

55. Disqualifying Defects (List by item number)

56. Medical Examiner’s Declaration - I hereby certify that I have personally reviewed the medical history and personaly examined the applicant
named on this medical examination report. This report, with any attachment, embodies my findings completely and correctly.
Exam Date
57. PHYSICIAN'S FULL NAME / ADDRESS / CITY / STATE / ZIP
MM
DD
YY
Physician’s Signature

JSC Form 1830  

Physician Telephone
(
)

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"CUI//SP-HLTH when filled in"
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Pursuant to the Privacy Act of 1974 5 U.S.C. § 552a , the following statement is SURYLGHGto individuals supplying information for inclusion in the
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AUTHORITY The collection of this information is authorized by 5 USC §7901; 51 U.S.C. § 20113(a); 44 U.S.C. §3101; DQG42 CFR Part 2.
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WKLVEXUGHQWR[email protected]. Current information regarding this collection of information - including all background
materials - can be found at https:/www.reginfo.gov/public/do/PRAMain using the search function to enter either the title of the collection or
2700-0170.

JSC Form 1830  

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