Department of State Academic Exchanges

Participant Medical History and Examination Form

Having been selected to participate in a U.S. Department of State educational exchange program, you are required to
submit a completed Medical History and Examination Form. The attached form should be completed and returned to:

You should complete Part I prior to the medical examination. Part II, the "Health History" and Part III, “Medical
Examination” must be completed by a qualified, licensed doctor or physician no more than six months before your grant
start date.

The purpose of these forms is to confirm health status for review and medical clearance, upon which a grant is contingent.
The information will also help your program staff be of maximum assistance to you should the need arise while you are on
a grant. Mild physical or psychological disorders can become serious under the stresses of life in an unfamiliar
environment. It is important that we be made aware of any medical, emotional or psychological problems, past or current,
which might affect you while on your program.

The Medical Information Form and Physician’s Statement should be completed in English by a licensed physician, doctor
(MD, DO, or foreign equivalent), or nurse practitioner who is not a member of your family and mailed to your program staff
before your participation in the program can be confirmed. Violation of this policy will result in the revocation of your
award. If the forms are completed by a health practitioner who is not an MD, DO, or nurse practitioner, it must be cosigned
by an MD or DO. Your award is contingent upon your submitting the Medical Information Form and Physician’s Statement
to your program staff by stated deadlines, and remains contingent until the information is reviewed and medical clearance
is issued.

INSTRUCTIONS TO PROSPECTIVE GRANTEES

In advance of your medical examination:

• Complete Part I on your own prior to the physical examination
• Sign and date the form on page 8.
• Familiarize yourself with the instructions to the physician.
• Understand the scope of the clinical examination and the tests required for your age and/or known condition so
that you can be sure that the requirements of the form will be met.
At the time of your medical examination:
• Assure that your health is evaluated in SECTIONS II AND III and that the form is signed by a physician. (Although
physicians' offices sometimes use a physician's assistant or R.N. to help perform the examination and tests, only a
physician or a nurse practitioner may sign the form.)
• Ask your physician to mail the completed form and test results to you as soon as possible. (If the form is
incomplete or if the results of the required tests are not reported, your program staff will return the form to you.
This step costs time and may require a return visit to the physician. Please prevent such delays.)

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PART I: TO BE COMPLETED BY PROSPECTIVE GRANTEE. Please type or print in ink

NAME: __________________________________________________________________________________________________
Last First Other

DATE OF BIRTH: _________________________ SEX: Male Female

Month/Day/Year
PRESENT ADDRESS:
___________________________________________________________________________________________
Home or Residence City Country

GRANT LOCATION: ________________________________ GRANT DATES:

(If known) City/Country _________________________________________________
From To

Will you be covered by private health insurance while on your program? If yes, complete the following information. As
well, please confirm with your provider that your coverage extends to your time overseas for your award. Be aware your
existing coverage will remain your primary insurance for the duration of your grant.

Name of Health Plan/ Health Care

Provider:

Health Plan ID#:

Health Plan Effective Date:

Health Care Provider Address:

Names of medical professionals consulted within the last 3 years, except for routine physical examinations. List your
primary care physician as well as any specialists. (Submit an additional form as needed).

NAME SPECIALTY or Primary Care TELEPHONE #:

Primary Care Physician

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EMERGENCY CONTACT INFORMATION and MEDICAL PROXY

Name two individuals who could be notified in case of emergency.

PRIMARY EMERGENCY CONTACT: SECONDARY EMERGENCY CONTACT:

Name: Name:
Address: Address:

Cell phone number: Cell phone number:

Home number: Home number:
Office number: Office number:
Email: Email:

While your academic exchange program does not require that you have established a medical proxy – a medical proxy is an
individual who is informed of and can make decisions about your medical wishes on your behalf if you are unable – it is
strongly recommended that you consider this option for any emergency medical situations that may result while you are
abroad. Should you already have a designated medical proxy, please indicate him/her below and provide a copy of the
documentation along with your medical examination results.

If you have a legal medical proxy, indicate him/her here and provide a copy of documentation. (Most U.S. states have
forms for the purpose of designating a medical proxy):

MEDICAL PROXY CONTACT (Optional):

Name:

Address:

Cell phone number:

Home number:

Office number:

Email:

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INSTRUCTIONS FOR THE EXAMINING PHYSICIAN

The individual you are examining is a candidate for an academic exchange program who will reside in another country.
Some locations are remote and may have limited medical support from doctors, nurses, laboratory facilities and hospitals.

Please evaluate thoroughly all items listed on the examination form. It is most important that you:

1. Comment on all items checked “yes” on the Medical History section (below).
2. Record all physical findings after completing the examination as requested. Only the results of a physical exam
performed no more than six months prior to the grant start date may be reported.
3. Order and record (or attach copies of) all relevant laboratory tests or necessary data. It is important that all of the
tests be reported as requested for the age or condition of the examinee. If there are test results within the past six
months, please attach those.
4. Comment on all indicated follow-up examinations and conditions that may require frequent observation or
prolonged treatment. Please indicate your overall opinion of the examinee’s health in items (page 8).
5. Sign and date the portion of the examination form that you completed (page 8).

PART II: TO BE COMPLETED BY PHYSICIAN

To be completed by the grantee’s physician in consultation with the candidate to determine what tests, if any, may be
required. For any items checked “Yes,” the physician may recommend a test to allow for further explanation of the
current status of the condition and/or the prognosis or outcome.

MEDICAL HISTORY
Does the grantee now have or have they ever had any of the conditions or symptoms listed below? Indicate “YES” or “NO”. “YES”
answers MUST be explained in the space provided following this section.
CHECK EACH ITEM YES NO YES NO
Frequent or severe headaches Fainting spells (syncope)
Epilepsy or seizures Heart condition incl. arrhythmia, angina, heart attack,
murmur, and heart failure
Stroke Eye disease or vision impairment (other than corrected
refractive error)
Hearing impairment Severe allergies, including environmental, insect stings,
food, and medication
Tooth or gum disease (periodontal disease) Tropical diseases, incl. malaria, amoebiasis, leprosy,
filariasis, etc.).
Asthma, emphysema, persistent cough, or other lung Depression, anxiety, excessive worry, schizophrenia,
conditions. psychosis
Tuberculosis Drug or alcohol abuse
High blood pressure Sickle cell anemia, excessive bleeding, blood clots or
other blood disorder
Gynecological disorder Cancer in any form
Other hormonal disorders, incl. thyroid HIV infection, AIDS
Diabetes mellitus (high blood sugar, sugar in urine) Severe skin disorder

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PART III. PHYSICAL EXAMINATION TO BE COMPLETED BY PHYSICIAN

If the grantee answered “YES” to any of the above, please explain in detail, including dates of occurrence, treatment and outcome.

Has the grantee ever had any significant or serious illness or injury not mentioned above? If so, explain the nature of the problem
and outcomes.

Please explain any operations (surgical procedures) the grantee has had that may impact grantee’s experience on the program.
Please explain.

Has the grantee ever been hospitalized for any reason? If so, explain what condition, provide dates, and explain the outcome.

Has the grantee ever seen a psychiatrist, psychologist, or psychotherapist? If so, explain for what condition and provide dates of
treatment and explain the outcome.

List all the medications taken by the grantee in the past three (3) years.

List all specific medications (generic or name brand) currently being taken by the grantee, whether on a regular or as needed
basis.

List all medical devices being used by the grantee (for example: insulin pump, prostheses, nebulizers).

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Note: Results of tests and x-rays included in this medical evaluation must be no more than six months prior to the date
of the participant’s arrival in or departure from the United States.

MEDICAL EXAMINATION FORM

THIS PHYSICAL EXAMINATION FORM MUST BE COMPLETED IN ENGLISH BY A DESIGNATED AND QUALIFIED PHYSICIAN AFTER REVIEWING THE
EXAMINEE’S MEDICAL HISTORY (PART II), CONDUCTING A PHYSICAL EXAMINATION, AND ASSESSING LABORATORY AND X-RAY RESULTS. THE
EXAMINING PHYSICIAN MUST COMMENT ON ALL POSITIVE AND/OR SIGNIFICANT FINDINGS AND SIGN WHERE INDICATED.
PLEASE TYPE OR PRINT IN INK

APPLICANT’S NAME: _________________________________________________________________________________________

Last First Other

HEIGHT: _____________________________ WEIGHT: ________________________________

(in or cm) (lb or kg)
1.
BLOOD PRESSURE: ___________________________________
2. RESTING HEART
Syst./diast. RATE:_____________________________
3.
CLINICAL EVALUATION
Please provide an answer to each item.
Abnormal findings must be fully explained in the space provided.

NORMAL ABNORMAL DESCRIBE ABNORMAL FINDINGS

Head and neck
Hearing Acuity
Visual Acuity (with corrective lenses, if
used)
Lungs and chest
Heart and vascular system
Abdomen
Breasts
Genito-urinary/Gynecologic
Musculoskeletal
Lymphatic
Neurologic
Skin
Psychiatric

A test for TB is required (for foreign grantees) at the time of examination, regardless of prior BCG vaccination. The PPD skin test or
interferon gamma release assay blood test is acceptable. PPD skin test results over 10mm require a chest X-ray. An abnormal result
on either test mandates a chest X-ray to evaluate for active tuberculosis.

Tuberculin Skin Test (PPD) Result (millimeters of induration): _____________________ Pos Neg

Date of test: ___________________________

OR
IGRA Test Date: _____________________ Pos Neg

Chest X-ray (if required) Date: _________________________

Chest X-ray findings:

(Note to Physician: X-ray images need not be submitted on film or otherwise)

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There are no specific laboratory tests required, although the exchange program may request further testing based on an
applicant’s medical history. Physicians are encouraged to obtain appropriate tests as indicated by the medical history
and results of the physical examination or place of grant activity (e.g., G6PD for malarial areas). For example, a diabetic
patient should have a recent blood sugar determination or patients with HIV infection should obtain a CD4 count.

NOTE: IT IS THE GRANTEE'S RESPONSIBILITY TO DETERMINE ANY TEST SPECIFICALLY REQUIRED BY HIS/HER HOST
COUNTRY.

VACCINATIONS. Below are the generally recommended vaccinations for foreign participants within the United States.

POLIO Dates of immunization:

(Three or more doses)
DIPHTHERIA, PERTUSSIS, TETANUS Dates of immunization:
(Three or more doses,
one within the past 10 years)
Date of immunization:
Measles – Mumps – Rubella (MMR)
(Or list individual Measles, Mumps, and
Rubella immunizations below)

MEASLES First immunization date:

Dates of Live Immunization
(two required, at least one month apart) Second immunization date:

(or) Indicate date of disease (or) Date of Disease:

(or) Indicate date and results of measles titer
(or) Date and result of measles titer:

MUMPS First immunization date:

Dates of Immunization
(two required, at least one month apart) Second immunization date:

(or) Indicate date of disease (or) Date of Disease:

(or) Indicate date and results of mumps titer
(or) Date and result of mumps titer:

RUBELLA First immunization date:

Dates of Immunization
(two required, at least one month apart) Second immunization date:

(or) Indicate date and results of rubella titer

(or) Date and result of rubella titer:
Note: History of disease is not acceptable
proof of immunity to rubella

NOTE: IT IS THE GRANTEE'S RESPONSIBILITY TO DETERMINE ANY VACCINATIONS SPECIFICALLY REQUIRED BY HIS/HER
HOST INSTITUTION AND/OR HOST COUNTRY.

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PHYSICIAN’S STATEMENT:

Based on your physical examination and on the candidate’s physical and emotional history, do you consider the
examinee physically and emotionally able to study, teach or conduct research in the country indicated on page 2 of
the form? (Circle one) Yes or No

If No, please explain:

PERSON COMPLETING THE PHYSICAL EXAMINATION:

Name Position Date

Signature of Examining /Supervising Physician:

_________________________________________________________________________Date:_____________________

Typed Name of Examining /Supervising Physician

____________________________________________________________________Telephone#:____________________

Address___________________________________________________________________________________________

PARTICIPANT'S STATEMENT:

I certify that I have reviewed the information supplied by me in Part I and to my physician in Part II and that it is true and
complete to the best of my knowledge. In the event of a serious illness or medical emergency during the grant activity, I
authorize release of my medical records to the U.S. Department of State or its designated contractual agency. I am
aware that the information in this form and any attachments, i.e., test results, etc. are being provided to my supervising
agency as part of the medical clearance process. I acknowledge that falsifying or knowingly excluding critical medical
information may jeopardize my program participation.

I understand that if any of this information is found to be substantially inaccurate or incomplete, it may be grounds for
termination of my grant and my return home.

Signature: ______________________________________________________________________Date:_______________

Privacy Policy: The information provided by you and your physician(s) will remain confidential and will be shared with your program
staff or appropriate professionals for grant administration purposes only.
Revision date: February 7, 2013
ECA/A/E