Form DS-1622

U.S. Department of State
Office of Medical Services, Room L101, SA-1, Washington, DC 20522-0102

*OMB APPROVAL NO. 1405-0068
EXPIRATION DATE: xx-xx-xxxx
ESTIMATED BURDEN: 1 HOUR

MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE
FOR INDIVIDUALS AGE 12 AND OLDER
PRIVACY ACT NOTICE

AUTHORITIES: The information is sought pursuant to the Foreign Service Act of 1980, as amended (22 U.S.C. §§ 4084, 3901, 3984).
PURPOSE: The information solicited on this form will be used to make appropriate medical clearance decisions.
ROUTINE USES: The information on this form maybe shared with personnel in the Office of Medical Services. Unless otherwise protected by medical
privacy regulations, the information may be made available to appropriate agencies, whether Federal, state, local or foreign, for law enforcement and
administration purposes. It may also be disclosed pursuant to court order. More information on the Routine Uses for the system can be found in the
System of Records Notice State-24, Medical Records.
DISCLOSURE: Providing this information is voluntary. However, failure to provide the information requested on this form may result in denial of a
medical clearance. Also, if you are an applicant to the Foreign Service, your failure to provide the information requested on this form may affect your
Foreign Service eligibility.
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 recommendations for reducing it, please send them to:
M/MED/EX, Room L217 SA-1, U.S. Department of State, Washington, DC 20522
I. To Be Filled Out By Examinee (Complete all sections, type or in ink.)
1. Name of Examinee (Last, First, MI.)

Date (mm-dd-yyyy)

2. Full Name of Employee/Applicant/Sponsor

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

3. eMED Number if known (Employee/Applicant/Sponsor)

5. Sex

7. Status
Male

Female

6. Place of Birth
City

State

Country

8. Name of your Health Insurance Plan

Applicant/Employee

Spouse

Son

Other

10. Agency of Employee/Applicant/Sponsor

In Service

Pre-Employment

Foreign Commercial
Service

State

USAID

Foreign Agricultural
Service

Board of Broadcasting Governors

9. Purpose of Exam
Separation

Daughter

11. Your Mailing Address (Medical Clearance Abstract will be mailed to listed 12. Post of Assignment and Dates of Departure/Arrival
address.)
a. Proposed Post
EDA
(mm-dd-yyyy)
Telephone Number
(where you can be
reached for the next
90 days)

b. Present Post
ED
(mm-dd-yyyy)
c. Last 3 Posts

E-mail (where you
can be reached for
the next 90 days)

To the Doctor: 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 member's 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-1843
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II. Have You Had In The Past 5 Years:
Yes

Name of Examinee:
Yes No

No

19. Rheumatologic-problems; tendon, joint or back pain/injury;
bone-deformity or fracture?

1. Frequent or severe headaches?
2. Dizzy spells, fainting, or seizures?

20. Malaria or other tropical disease?

3. Neurological disorders?

21. Any hair, nail or skin problems or disorders?

4. Chronic eye trouble, or vision problems?

22. Diabetes; thyroid or other hormonal/metabolic disease?

Date of last eye exam (mm-dd-yyyy)
5. Tooth or gum problems?
6. Ear, nose, or throat problems, including
hearing difficulties, hoarseness, or allergies?

23. Anemia or blood transfusion?

7. Cough, wheezing, shortness of breath or asthma?

25. Recent gain or loss of 10 lbs or more?

8. Abnormal chest X-ray
9. History of positive TB skin test or clinical
tuberculosis, TB exposure, or BCG vaccination?

26. Thickening or lump in breast, testicle or elsewhere?

24. Have you ever had an organ transplant or been an organ
donor?

27. Felt unusually depressed, sad, blue or had frequent crying
spells?

10. Palpitations, chest pressure, murmurs or any
other heart problems?

28. Difficulty in relaxing or calming down; felt panicky, irritable,
angry, hyper or nervous?

11. History of aneurysm or blood clots?

29. Special education needs?

12. High blood pressure or high cholesterol ?

30. Have you ever used tobacco products?

13. Esophagus, stomach, intestinal, rectal, liver,
gallbladder problems or hernia?

31. Have you ever used alcohol?
32. Have you used marijuana, hallucinogenic drugs, narcotics,
or cocaine in the last 10 years?

14. Have you had a colonoscopy or sigmoidoscopy?
Date (mm-dd-yyyy)

33. Have you ever been referred to or received mental health
treatment?

15. A change in urinary habits, urinary tract infection
or stones, blood or protein in urine?
16. Sexually-transmitted disease?
17. Serious infection?

Primary Care PTSD Screen
This questionnaire is intended to help you identify if you have the symptoms of
Post-Traumatic Stress Disorder (PTSD). Please answer the following four questions if
you have been assigned to a danger pay post in the last three years.
In your life, have you ever had any experience that was so frightening, horrible, or
upsetting that, in the past month you:

18. Cancer of any type?

34. Have had nightmares about it or thought about it when you
did not want to?
35. Tried hard not to think about it or went out of your way to
avoid situations that reminded you of it?
36. Were constantly on guard, watchful, or easily startled?
37. Felt numb or detached from others, activities, or your
surroundings?

Women Only

40. Have you ever had a mammogram?

38. Do you have menstrual cycles?
Date of last menstrual period

41. Are you pregnant?

39. Have you had an abnormal PAP test in the last
5 years?

42. Are you nursing?
Pregnancy History: (number of times)

Date (mm-dd-yyyy) of last PAP test
Date (mm-dd-yyyy) of abnormal PAP

Pregnant

Result

Premature births

Miscarriages
Abortions

Live births
Living children

III. Hospitalizations/Operations/Medical Evacuations (Include all medical and psychiatric illnesses.)
Date (mm-dd-yyyy)

Illness or Operation

Name of Hospital

City and State

Please recheck all items for completeness and accuracy. DO NOT INDICATE: "Previously Answered."
IV. Explanations required for "yes"answers to questions 1 to 42. Attach additional sheet.
The intentional omission of any crucial medical information is a criminal offense (Section 1001 of the U.S.C. Title 18). Pre-employment applicants who
intentionally omit information which would make them ineligible for appointment, will be subject to disciplinary action, including separation for cause if
they are hired. Current employees may also be subject to disciplinary action for intentional omission of information.
Signature of Examinee (I certify I have read and understand the above statements).

Date (mm-dd-yyyy)

V. Examiner Comments on Significant History and Examination Findings: Comment on all items checked YES in section II.

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VI. To Be Completed By The Examiner

Name Of Examinee:
3. Pulse

2. Weight

1. Height
in. or

lbs. or

cm.

kgs.

4. Blood Pressure (sitting) If above 140/85 repeat 3
times and record. If consistently elevated
consider treatment.

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

Normal Abnormal

NE

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

1. General/Constitution
2. Skin
3. Eyes
4. Ears/Nose/Throat
5. Neck/Thyroid
6. Lungs/Thorax
7. Breasts
8. Cardiovascular
9. Abdomen
10. Male Genitalia
11. Anus/Rectum/Prostate
12. Musculoskeletal
13. Lymphatic
14. Neurological
15. Female Gynecologic
16. Miscellaneous
17. Papanicolaou done

Not done

Reason if not done

18. Attach cytology report.
VIII. List Current Medications (Include prescription, over the counter, vitamins, and herbals)

Drug Or Other Allergies

IX. Instructions

Disposition of Records:
Examinee or sponsor must sign on page 2. Medical provider must sign on page 4.
All reports must be in English and identified with the full name and date of birth of the examinee.
Do Not Submit Reports by US Mail.
Do Not Submit Reports by Professional Courier Service (e.g. FedEx or DHL).
Keep originals as a permanent record.
For U.S. Department of State Health Units:
The preferred method to submit the DS-1843 is by way of eForms to Medical Records. If this is not possible, please submit the
completed document by FAX.
For Private Health Care Providers:
Please FAX the completed DS-1843 directly to Medical Records.

Department of State, Medical Records:
The preferred method to submit the DS-1843 is to scan and send by email to: MEDMR@state.gov.
If it is not possible to scan, then please fax the DS-1843 to Medical Records at Fax: 703-875-4850.
If you wish to confirm that your exam forms were received please email MEDMR@state.gov

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X. All Tests Required Unless Otherwise Specified. Please attach all reports.

Name of Examinee:

1. Hematology

6. Urinalysis (when indicated)

Hematocrit

Differential
%

or

Granulocytes

%
%

Hemoglobin

gms%

Lymphocytes

WBC

/cmm

Eosinophils

%

Other

%

2. Screening Chemistry (pre-employment and at least every 5 years)
Blood Sugar

Creatinine

Cholesterol

ALT

HDL/LDL

GGT

Triglycerides

HbA1C (when indicated)

3. Serology (specify test and results) (12 years and over for
pre-employment and approx. every 5 years after)

HIV I/II antibody
HepB surface antigen (if
known HBsAb pos. or has had
immunization, do not repeat)

Pos

Neg

b.

Pos

Neg

c.

Pos

Neg

Albumin

RBC

Sugar

Casts

7. ECG (50 years or earlier when indicated. All pre-employment 40
years and above. Submit all tracings.)
Results
8. Chest X-Ray (required for persons 18 years and over for
pre-employment and separation, for new TB skin test converters or
when indicated. If pregnant, baseline chest X-ray required after
delivery)
Date (mm-dd-yyyy)

Results
11. Pre-employment
and in Service if
not previously
done. (not for
separation)

If Not Done, Explain
Results:

HepC antibody

a.

WBC

9. Tuberculin Test (5TU PPD)
(recommended for all examinees including
those with previous BCG)
Date (mm-dd-yyyy)

RPR/VDRL

4. Stool Exam for Occult Blood
(50 years or earlier when
indicated)

Specific
Gravity

5. Colon Screen
(age 50 or when indicated by
risk factors according to
current standards of care)
Barium Enema, or
Colonoscopy.
Attach most recent results.

mm of Induration

a. Blood Type

Previous Positive

Yes

No

ABO

Previous Rx Complete

Yes

No

(Rh) D

Date Completed (mm-dd-yyyy)
New Converter
(X-Ray required)

u

(weak) D
Yes

No

Treatment

5. Mammogram (required age 50 years or when indicated by risk factors according to current standards of care. Attachment most recent result )

XI. Assessment Or Problem List

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

Typed Name of Examiner

Signature

Examining Facility
Telephone Number

Address

Date (mm-dd-yyyy)

Fax Number
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