Form I-693 - Report Of Medical Examination And Vaccination Record Page 8
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13Family Name (Last Name)
Given Name (First Name)
Middle Name
A-Number (if any)
A-
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Part 7. Civil Surgeon Worksheet (continued)
(2)
Findings:
No Class A or Class B Gonorrhea
Gonorrhea, Class A (untreated)
Gonorrhea, Class B (treated in the last year)
(3)
Remarks: (Include any treatment given with doses and dates)
Drug:
Dosage:
Start Date (mm/dd/yyyy)
End Date (mm/dd/yyyy)
D.
Other Class A/Class B Conditions for Communicable Diseases of Public Health Significance
(1)
Findings:
(a)
No Class A/B Condition
(b)
Hansen's Disease (leprosy, any classification) untreated, Class A
Indeterminate, tuberculoid, borderline tuberculoid (paucibacillary)
Mid-borderline, borderline lepromatous, lepromatous (multibacillary)
(c)
Hansen's Disease (leprosy, any classification) treated or partially treated,
Class B
Indeterminate, tuberculoid, borderline tuberculoid (paucibacillary)
Mid-borderline, borderline lepromatous, lepromatous (multibacillary)
(2)
Remarks: (Include any therapy given and any counseling or referrals) If you need extra space to complete this section,
use the space provided in Part 10. Additional Information.
2.
Physical or Mental Disorders With Associated Harmful Behavior
Include here any physical or mental disorders with current associated harmful behavior or history of associated harmful behavior
judged likely to recur. This category of physical or mental disorders includes any diagnosis of substance-related disorders that
involve any substance that is not listed in Schedule I, II, III, IV, or V of section 202 of the Controlled Substances Act (for example,
diagnosis of an alcohol-related disorder). Diagnose mental disorders according to the diagnostic criteria in the most recent edition
of the Diagnostic and Statistical Manual (DSM) or another authoritative source, as determined by the director of the CDC.
Diagnose physical disorders according to the diagnostic criteria in the most recent edition of the World Health Organization's
Manual of the International Classification of Diseases, Injuries, and Causes of Death (ICD) or another authoritative source as
determined by the director of the CDC. See the CDC's Technical Instructions for more information.
A.
Findings:
(1)
No Class A or B Physical or Mental Disorder
(2)
Current Physical/Mental Disorder with Associated Harmful Behavior, Class A
(3)
History of Physical/Mental Disorder with Associated Harmful Behavior Likely to Recur, Class A
(4)
Current Physical/Mental Disorder without Associated Harmful Behavior, Class B
(5)
History of Physical/Mental Disorder with Associated Harmful Behavior Unlikely to Recur, Class B
Form I-693 10/19/17 N
Page 8 of 13
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