Form DS-3026 "Medical History and Physical Examination Worksheet"

What Is Form DS-3026?

This is a legal form that was released by the U.S. Department of State on September 1, 2014 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2014;
  • The latest available edition released by the U.S. Department of State;
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  • Fill out the form in our online filing application.

Download a fillable version of Form DS-3026 by clicking the link below or browse more documents and templates provided by the U.S. Department of State.

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U.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
U.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
4. Vital Signs and Vision
Height
cm
BP
/
Temperature
°C
Visual acuity at 20 feet:
Weight
kg
Pulse
/ min
Uncorrected L 20/
R 20/
Respiratory
BMI
kg/m²
Rate
/ min
Corrected
L 20/
R 20/
5. Physical Examination (include all findings and give details in Remarks)
N, normal; A, abnormal
N
A
N
A
General appearance
Inguinal region (including adenopathy)
Nutritional status (including acute wasting and or chronic stunting
Musculoskeletal system (including gait)
Extremities (including pulses, edema)
malnutrition)
Hearing and ears
Skin (including hypopigmentation or anesthesia consistent with
Eyes
Hansen's Disease, evidence of self-inflicted injury or injections)
Nose, mouth, and throat (include detail)
Hematologic (including signs of anemia such as pallor, koilonychia)
Heart (S1, S2, murmur, rub)
Lymph nodes
Lungs
Nervous system (including nerve enlargement)
Abdomen (including liver, spleen)
Mental status (including mood, intelligence, perception, thought
Genitalia (including infection(s))
processes, and behavior during examination)
6. Mental Health Specialist
Referral made to mental health specialist. If so, attach report.
7. Syphilis Laboratory Results and Treatment
Laboratory testing not done
Date specimen reported
Test Name
Positive
Negative
Initial Titer
(mm-dd-yyyy)
Screening
Confirmatory
Treated
If treated, therapy:
Date(s) treatment given (mm-dd-yyyy)
Yes
Benzathine penicillin, 2.4 MU IM
No
Other (therapy, dose):
Treated by panel physician:
Yes
No
Stage of syphilis (mark one):
Primary
Tertiary
Secondary
Neurosyphilis
Early latent
Congenital
Late latent or latent of
unknown duration
8. Diagnosis and Treatment of Other Sexually Transmitted Infections
Infection:
Chancroid
Gonorrhea
Granuloma inguinale
Lymphogranuloma venereum
Diagnosed by panel physician:
Yes
No
Treated by panel: physician:
Yes
No
Drug
Dosage
Start Date (mm-dd-yyyy)
End Date (mm-dd-yyyy)
DS-3026
Page 2 of 3
9. Diagnosis and Treatment for Hansen's Disease
Type of Hansen's Disease
Treatment
Multibacillary
Partial
Drug
Dosage
Start Date (mm-dd-yyyy)
End Date (mm-dd-yyyy)
Paucibacillary
Completed
Treated by panel physician
Yes
No
If not treated by panel physician, was referral made by panel physician to another provider for treatment:
Yes. Provide facility name:
No
Diagnosis
Initial diagnosis made by panel physician
Initial diagnosis made by non-panel physician before medical evaluation by panel physician
If so, year of diagnosis:
10. Remarks
PAPERWORK REDUCTION ACT AND CONFIDENTIALITY STATEMENTS
PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average 30 minutes 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: PRA_BurdenComments@state.gov
CONFIDENTIALITY STATEMENT
AUTHORITIES The information asked for on this form is requested pursuant to Section 212(a) and 221(d) and as required by Section 222 of the
Immigration and Nationality Act. Section 222(f) provides that the records of the Department of States and of diplomatic and consular offices of the
United States pertaining to the issuance and refusal of visas or permits to enter the United States shall be considered confidential and shall be used
only for the formulation, amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified
copies of such records may, in the discretion of the Secretary of State, be made available to a court provided the court certifies that the information
contained in such records is needed in a case pending before the court.
PURPOSE The U.S. Department of State uses the facts you provide on this form primarily to determine your classification and eligibility for a U.S.
immigrant visa. Individuals who fail to submit this form or who do not provide all the requested information may be denied a U.S. immigrant visa.
Although furnishing this information is voluntary, failure to provide this information may delay or prevent the processing of your case.
ROUTINE USES If you are issued an immigrant visa and are subsequently admitted to the United States as an immigrant, the Department of
Homeland Security will use the information on this form to issue you a Permanent Resident Card, and, if you so indicate, the Social Security
Administration will use the information to issue a social security number. The information provided may also be released to federal agencies for law
enforcement, counterterrorism and homeland security purposes; to Congress and courts within their sphere of jurisdiction; and to other federal
agencies who may need the information to administer or enforce U.S. laws. More information on the Routine Uses for this collection can be found in
the System of Records Notice State-24, Medical Records.
DS-3026
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