Medical Examination For Immigrant Or Refugee Applicant Page 7

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U.S. Department of State
OMB No. 1405-0113
EXPIRATION DATE: 09/30/2010
MEDICAL HISTORY AND PHYSICAL EXAMINATION WORKSHEET
ESTIMATED BURDEN: 35 minutes
For use with DS-2053
(See Page 2 - Back of Form)
Name (Last, First, MI)
Exam Date (mm-dd-yyyy)
Alien (Case) Number
Passport Number
Birth Date (mm-dd-yyyy)
1. Past Medical History (indicate conditions requiring medication or other treatment after resettlement and give details in Remarks)
NOTE:
The following history has been reported, has not been verified by a physician, and should not be deemed medically definitive.
No Yes
No Yes
General
Ever caused SERIOUS injury to others, caused MAJOR
Illness or injury requiring hospitalization (including psychiatric)
property damage or had trouble with the law because of
medical condition, mental disorder, or influence of alcohol or
Cardiology
drugs
Angina pectoris
Obstetrics and Sexually Transmitted Diseases
Hypertension (high blood pressure)
Pregnancy
Fundal height
cm
Cardiac arrhythmia
Last menstrual period Date (mm-dd-yyyy)
Congenital heart disease
Sexually transmitted diseases, specify
Pulmonology
History of tobacco use
Endocrinology and Hematology
Current use
Yes
No
Diabetes mellitus
Asthma
Chronic obstructive pulmonary disease (emphysema)
Thyroid disease
History of malaria
History of tuberculosis (TB) disease
Treated
Yes
No
Other
Malignancy, specify
Current TB symptoms
Yes
No
Neurology and Psychiatry
Chronic renal disease
History of stroke, with current impairment
Chronic hepatitis or other chronic liver disease
Seizure disorder
Hansen's Disease
Major impairement in learning, intelligence, self care, memory, or
Tuberculoid
Borderline
Lepromatous
communication
OR
Paucibacillary
Multibacillary
Major mental disorder (including major depression, bipolar disorder,
schizophrenia, mental retardation)
Treated
Yes
No
Use of drugs other than those required for medical reasons
Visible disabilities (including loss of arms or legs),
Addiction or abuse of specific* substance (drug)
specify
*amphetamines, cannabis, cocaine, hallucinogens, inhalants,
opioids, phencyclidines, sedative-hypnotics, and anxiolytics
Other substance-related disorders (including alcohol addiciton or
Other requiring treatment, specify
abuse)
Ever taken action to end your life
2. Physical Examination (indicate findings and give details in Remarks)
Applicant appears to be providing unreliable or false information, specify
No
Yes
cm
kg
Height
Weight
Visual Acuity at 20 feet: Uncorrected L 20/
R 20/
/
(mmHg)
Heart rate
Respiratory rate
/min
Corrected L 20/
R 20/
BP
/min
*N, normal;
A, abnormal; ND, not done
N*
A* ND*
N*
A* ND*
General appearance and nutritional status
Inguinal region (including adenopathy)
Hearing and ears
Extremities (including pulses, edema)
Eyes
Musculoskeletal system (including gait)
Nose, mouth, and throat (include dental)
Skin
(including
hypopigmentation,
anesthesia,
findings
consistent with self-inflicted injury or injections)
Heart (S1, S2, murmur, rub)
Lymph nodes
Breast
Nervous system (including nerve enlargement)
Lungs
Mental status (including mood, intelligence, perception,
Abdomen (including liver, spleen)
thought processes, and behavior during examination)
Genitalia (including circumcision, infection(s))
DS-3026
Page 1 of 2
09-2007

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