Ds-3026 Form - Medical History And Physical Examination Worksheet
Download a blank fillable Ds-3026 Form - Medical History And Physical Examination Worksheet in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Ds-3026 Form - Medical History And Physical Examination Worksheet with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3U.S. Department of State
OMB No. 1405-0113
MEDICAL HISTORY AND
EXPIRATION DATE: 09/30/2017
ESTIMATED BURDEN: 30 minutes
PHYSICAL EXAMINATION WORKSHEET
(See Page 2 - Back of Form)
For Use with DS-2054
Photo
Name (Last, First, MI)
Exam Date (mm-dd-yyyy)
Birth Date (mm-dd-yyyy)
Passport Number
Alien (Case) Number
1. Past Medical History
No
Yes
No
Yes
General
Obstetrics and Sexually Transmitted Diseases
Illness or injury requiring hospitalization (including psychiatric)
Pregnancy, current
Estimated delivery date (mm-dd-yyyy)
Cardiology
Pregnancy, birth dates (mm-dd-yyyy)
Hypertension
Congestive heart failure or coronary artery disease
Arrhythmia
Rheumatic heart disease
Congenital heart disease
Previous treatment for sexually transmitted diseases, specify
date (mm-yyyy) and treatment:
Pulmonology
Chancroid
Tobacco use:
Current
Former
Gonorrhea
Asthma
Granuloma inguinale
Chronic obstructive pulmonary disease
Lymphogranuloma venereum
Tuberculosis history: Diagnosed (mm-yyyy)
Syphilis
Treated (mm-yyyy)
Fever
Endocrinology
Cough
Diabetes mellitus
Night sweats
Thyroid disease
Weight loss
Hematologic/Lymphatic
Psychiatry
Anemia
Major impairment in learning, intelligence, self-care, memory, or
Sickle Cell Disease
communication
Thalassemia major
Major mental disorder (including bipolar disorder, major
Other hemoglobinopathy
depression, mental retardation, post-traumatic stress disorder,
schizoaffective disorder, schizophrenia)
Other
HIV: if previously tested, mm-yyyy of test
Use of drugs other than those required for medical reasons
Wears glasses or contact lenses
Addiction (dependence) or abuse of specific substances or drugs
Malignancy, specify:
on the CSA
Other substance related disorders (including alcohol abuse or
Chronic renal disease
Chronic liver disease (including hepatitis)
dependence)
Ever caused serious injury to others, caused major property
Hansen's Disease: Diagnosed (mm-yyyy)
Treated (mm-yyyy)
damage or had trouble with the law because of medical condition,
mental disorder, or influence of alcohol or drugs
Other medical conditions requiring treatment, specify:
Ever had thoughts of harming yourself
Ever acted on those thoughts
Ever had thoughts of harming others
Ever acted on those thoughts
Disabilities (including loss of arms or legs), specify:
Neurology
History of stroke
Seizure disorder
Applicant appears to be providing unreliable or false
information, specify in remarks
2. Current Medications (List all current medications)
3. Previous Surgeries (List all previous surgeries)
DS-3026
Page 1 of 3
09-2014
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal