Medical Examination For Immigrant Or Refugee Applicant

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U. S. Department of State
OMB No. 1405-0113
MEDICAL EXAMINATION FOR
EXPIRATION DATE: 09/30/2010
ESTIMATED BURDEN: 10 minutes
IMMIGRANT OR REFUGEE APPLICANT
(See Page 2 - Back of Form)
Name (Last, First, MI.)
,
,
Photo
Birth Date (mm-dd-yyyy)
M
F
Sex:
Birthplace (City/Country)
/
Prior Country
Present Country of Residence
U.S. Consul (City/Country)
/
Passport Number
Alien (Case) Number
Date (mm-dd-yyyy) of Medical Exam
Date (mm-dd-yyyy) of Prior Exam, if any
Date Exam Expires (6 months from examination date, if Class A or TB condition exists, otherwise 12 months) (mm-dd-yyyy)
Exam Place (City/Country)
Panel Physician
/
Radiology Services
Screening Site (name)
Lab (name for HIV/syphilis/TB)
/
/
(1) Classification (check all boxes that apply):
No apparent defect, disease, or disability (see Worksheets DS-3024, DS-3025 and DS-3026)
Class A Conditions (From Past Medical History and Physical Examination Worksheets)
TB, active, infectious (Class A, from Chest X-Ray Worksheet)
Human immunodeficiency virus (HIV)
Syphilis, untreated
Hansen's disease, lepromatous or multibacillary
Addiction or abuse of specific* substance without harmful
Chancroid, untreated
behavior
Gonorrhea, untreated
Any physical or mental disorder (including other
Granuloma inguinale, untreated
substance-related disorder) with harmful behavior or history of
such behavior likely to recur
Lymphogranuloma venereum, untreated
*amphetamines, cannabis, cocaine, hallucinogens, inhalants,
opioids, phencyclidines, sedative-hypnotics, and anxiolytics
Class B Conditions (From Past Medical History and Physical Examination Worksheets)
TB, active, noninfectious (Class B1, from Chest X-Ray Worksheet)
Hansen's disease, prior treatment
Hansen's disease, tuberculoid, borderline, or paucibacillary
Treatment:
None
Partial
Completed
Sustained, full remission of addiction or abuse of specific*
TB, inactive (Class B2, from Chest X-Ray Worksheet)
substances
None
Treatment:
Partial
Completed
Any physical or mental disorder (excluding addiction or abuse of
See Section 4 on page 2 for TB treatment details
specific* substance but including other substance-related
disorder) without harmful behavior or history of such behavior
Syphilis (with residual deficit), treated within the last year
unlikely to recur
Other sexually transmitted infections, treated within last year
*amphetamines, cannabis, cocaine, hallucinogens, inhalants,
Current pregnancy, number of weeks pregnant
opioids, phencyclidines, sedative-hypnotics, and anxiolytics
Other (specify or give details on checked conditions from worksheets)
(2) Laboratory Findings (check all boxes that apply):
Syphilis:
Not done
Test name
Date(s) run (mm-dd-yyyy)
Negative
Positive
Titer 1
Notes
Screening
Confirmatory
Treated
If treated, therapy:
Date(s) treatment given (3 doses for penicillin)
Yes
Benzathine penicillin, 2.4 MU IM
No
Other (therapy, dose):E
HIV:
Not done
Test name
Date(s) run (mm-dd-yyyy)
Negative
Indeterminate
Notes
Positive
Screening
Secondary
Confirmatory
DS-2053
(Formerly OF-157)
Page 1 of 2
09-2007

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