Department of State Academic Exchanges

Participant Medical History and Examination Form

Fulbright Foreign Student Program

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:

Participants will complete Parts I, II, III, and IV prior to the medical examination. If the space provided is not sufficient, you may
attach additional pages. Parts V, VI, VII, and VIII must be completed by a qualified, licensed doctor or physician no more than six (6)
months before your grant start date.

The purpose of these forms is to confirm health status and plans for continuing care in your host country, as well as for medical
clearance, upon which a grant is contingent. The information will also help Fulbright 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 program administrators be made aware of any medical, emotional or
psychological conditions, past or current, which might affect you while on your program. Failure to disclose your current medical
issues or medical history to your medical examiner may result in termination or revocation of your grant.

The Medical Examination History (Part VI), Medical Examination Report (Part VII), and Physician’s Statement (Part VIII) 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 returned to your program staff before your participation in the program can be confirmed. Violation of this policy
may result in termination or 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 History and
Examination Form by stated deadlines and remains contingent until the information is reviewed and medical clearance is issued.

INSTRUCTIONS TO PARTICIPANTS

In advance of your medical examination:

• Complete Parts I, II, III, and IV on your own prior to the physical examination.
• If the space provided for further explanation is not sufficient, you may attach additional pages. Be sure to note this in the
response box, e.g., continued on a separate page.
• 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:
• Ensure that your health is evaluated in Parts VI and VII 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 return the completed report, including his/her signature and title, and test results to you as soon as
possible.
• Check the form to make sure that Parts VI, VII, and VIII have been completed by the doctor. If the form is incomplete, illegible,
or if the results of the required tests are not reported, Fulbright 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.
Following the medical examination:
• Compile your medical report to include pages 2-11. Insert additional statements and test results following the relevant pages.
• Sign and date the form on page 11.
• Scan the entire report into a single PDF or JPG document. These are the only acceptable upload formats.
• Ensure that your scan is legible, complete, and in the correct order before uploading.
• Name your scanned document: Nominating Country-Last Name-First Name-MedForm (example: Vietnam-Jones-John-
MedForm)

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 PART I: PARTICIPANT BACKGROUND AND CONTACT INFORMATION: To be Completed by Participant

For Parts I-IV, please type or print in ink and print prior to medical examination.

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? Yes No

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:

Please provide the 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: To be Completed by Participant

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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 PART II: PARTICIPANT MEDICAL HISTORY: To be Completed by Participant

To be completed by the participant prior to the Medical Examination.

Have you ever been diagnosed with/treated for any of the following conditions? Please indicate by answering YES or NO.
YES answers must be explained in the space below, indicating dates, nature of diagnosis and treatment, as well as the
current status. Attach additional pages if necessary. Further explanation may be required in Part VI which is completed by
the physician conducting the medical examination.

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
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 Severe skin disorder
other lung conditions
Tuberculosis HIV infection, AIDS

High blood pressure Cancer in any form

Gynecological disorder Depression, anxiety, excessive worry, or

related condition
Hormonal disorders, incl. thyroid Schizophrenia, psychosis, bipolar
disorder, or related condition
Diabetes mellitus (high blood sugar, sugar in Anorexia, bulimia, obsessive-compulsive
urine) disorder or related condition
Sickle cell anemia, excessive bleeding, blood Drug or alcohol abuse
clots or other blood disorder

Please explain any items above to which you answered YES, as well as any other health conditions (physical or
psychological) you have experienced in the last three (3) years. Please include diagnosis, dates of occurrence, type and
dates of treatment, medications, outcome, and current status. Attach additional pages if necessary.

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 PART III: VACCINATION HISTORY: To be Completed by Participant

To be completed by the participant prior to the Medical Examination. NOTE: COMPLETION OF THIS SECTION IS
RECOMMENDED, BUT NOT REQUIRED. IT IS THE PARTICIPANT'S RESPONSIBILITY TO DETERMINE ANY TEST SPECIFICALLY
REQUIRED BY THE HOST COUNTRY. If exact dates of immunizations are not known, list month and year or just year.

Below are the generally recommended vaccinations for foreign participants traveling to the United States only. Individuals are
advised to consult the CDC travel website: http://wwwnc.cdc.gov/travel/destinations/list
POLIO (Three or more doses) Dates of immunization:

DIPHTHERIA, PERTUSSIS, TETANUS Dates of immunization:

(Three or more doses, one within the past 10 years)

MEASLES – MUMPS – RUBELLA (MMR) (Or list individual Date of immunization:

Measles, Mumps, and Rubella immunizations below)

MEASLES Dates of Live Immunization (two required, at First immunization date:

least one month apart)
Second immunization date:
(or) Indicate date of disease
(or) Indicate date and results of measles titer (or) Date of Disease:
(or) Date and result of measles titer:

MUMPS Dates of Immunization (two required, at least one First immunization date:
month apart)
Second immunization date:
(or) Indicate date of disease
(or) Indicate date and results of mumps titer (or) Date of Disease:
(or) Date and result of mumps titer:

RUBELLA Dates of Immunization (two required, at least First immunization date:

one month apart)
(or) Indicate date and results of rubella titer Second immunization date:
Note: History of disease is not acceptable proof of
immunity to rubella (or) Date and result of rubella titer:

COVID-19 Vaccinations First Dose details:

(Please list manufacturer and date for each dose)
Second Dose details:

Other Dose details:

Booster / Add’l Doses:

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 PART IV: PLAN FOR CONTINUING CARE WHILE ON GRANT: To be Completed by the Participant

To be completed by the participant prior to the Medical Examination.

It is important that you consider how you will manage your physical and psychological health needs while overseas. If you
have a condition that requires ongoing care (e.g. monitoring or testing, maintenance medication, medical devices or supplies)
you must plan in advance to safeguard your wellbeing.

You should ensure that you understand the Accident and Sickness Program for Exchanges (ASPE), which is a limited health
benefit plan provided to exchange participants while on program in their host country. Please review the ASPE Benefits Guide
available at https://www.sevencorners.com/about/gov/usdos, including the following sections:
• Benefit Coverage, beginning on page 9
• Benefit Exclusions, beginning on page 12
• Inside the U.S.: Medical Provider Network, found on page 15
• Inside the U.S.: Prescription Drugs, beginning on page 17
• Mental Health Support Hotline, found on page 21

You should evaluate your specific health needs to determine whether you need to continue your current health insurance
coverage and/or garner additional health insurance coverage while overseas, in addition to ASPE coverage.

Please provide evidence of your advanced planning by responding to the questions below:

1. If you plan to regularly meet with a health care provider or mental health professional while on grant, please specify what
type of provider (e.g. neurologist, oncologist, psychiatrist, etc.), the condition being treated, and the anticipated frequency
of appointments.

2. Specify the monitoring or testing, medications, medical devices, and/or medical supplies that you will require while on
grant and the condition they treat (such as anxiety, bipolar disorder, depression, diabetes, high blood pressure, etc.).

3. Detail your plans for securing the care specified above in questions 1 and/or 2 while in the United States. (Due to
regulations regarding controlled substances and/or prescription medications, drugs available overseas are not necessarily
available in the United States. For more information refer to the ASPE Benefits Guide.)

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 PART V: INSTRUCTIONS FOR THE EXAMINING PHYSICIAN

The individual you are examining is a candidate for an academic exchange program who will reside in the United States. Some
locations are remote and may have limited medical support from doctors, nurses, laboratory facilities and hospitals. You are
asked to carefully consider the applicant’s general fitness and physical and psychological health in relation to the host country
conditions.

Please evaluate thoroughly all items listed above in Part II: PARTICIPANT MEDICAL HISTORY, Part III: VACCINATION HISTORY,
and Part IV: PLAN FOR CONTINUING CARE WHILE ON GRANT. It is most important that you:
• Discuss medical history with the participant, conduct a general medical examination, and respond to the questions on
pages 8, 9, and 10.
• If the space is not sufficient for a thorough explanation, please feel free to attach additional pages.
• Enter N/A in the space if the question is not applicable to the participant.
• There are no specific laboratory tests required, although the exchange program may request further testing based
on the participant’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. For example, G6PD for participants in malarial
areas, recent blood sugar determination for diabetic patients or CD4 counts for patients with HIV infection.
• Order and record (or attach copies of) all relevant laboratory tests or necessary data. If there are test results within
the past twelve months, please also attach.
• After completing the medical examination, record all findings on pages 8, 9, and 10. Only the results of a physical exam
performed no more than six (6) months prior to the grant start date may be reported.
• 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 on page 11.
• Sign and date page 11.

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 PART VI: MEDICAL EXAMINATION HISTORY: To Be Completed by Physician

If the participant answered “YES” to any of the conditions listed in the medical history in Part II, please discuss with participant
and comment below. Include dates of occurrence, treatment and outcome, if not indicated in the participant’s explanation,
and if and how the condition may impact participation in the program abroad.

Has the participant ever had any significant or serious illness or injury not mentioned in the medical history? If so, explain the
nature of the problem and outcome.

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

Has the participant ever been hospitalized for any reason? If so, list the condition(s), provide dates of treatment, and explain
the outcome.

Has the participant ever seen a psychiatrist, psychologist, or psychotherapist? If so, list the condition(s), provide dates of
treatment, and explain the outcome.

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 PART VII. MEDICAL EXAMINATION REPORT: To be Completed by Physician

THIS MEDICAL EXAMINATION REPORT MUST BE COMPLETED IN ENGLISH BY A DESIGNATED AND QUALIFIED DOCTOR,
PHYSICIAN OR NURSE PRACTITIONER AFTER REVIEWING THE EXAMINEE’S MEDICAL HISTORY (PART II) AND PLAN FOR
CONTINUING CARE WHILE ON GRANT (PART IV), CONDUCTING A PHYSICAL EXAMINATION, AND ASSESSING LABORATORY AND
X-RAY RESULTS. THE EXAMINING PHYSICIAN MUST COMMENT ON ALL POSITIVE AND/OR SIGNIFICANT FINDINGS IN THE SPACE
PROVIDED.
Note: Results of tests and X-rays included in this medical evaluation must be no more than six (6) months prior to the date of
the participant’s departure from the United States.
Please type or print in ink.
PARTICIPANT’S NAME:
_______________________________________________________________________________________________
Last First Other
HEIGHT: (in or cm) _________________________ WEIGHT: (lb or kg) _________________________

BLOOD PRESSURE: Syst./diast. _________________________ RESTING HEART RATE: ____________________

CLINICAL EVALUATION
Please provide an answer to each item.
Abnormal findings must be fully explained in the space provided. Attach additional pages if needed.
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.

List all the medications taken by the participant in the past two (2) years.

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

List all medical devices being used by the participant (e.g. CPAP machine, glucose monitor, prosthesis, etc.).

List any laboratory tests administered as part of this medical examination. Indicate type of, and reason for, test and the
results. Attach additional information or documentation where appropriate.

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 PART VIII: PHYSICIAN’S STATEMENT: To be Completed by Physician
Based on your physical examination and on the participant’s physical and psychological history, including the Plan for Continuing Care
While on Grant, do you consider the examinee physically and emotionally able to study, teach or conduct research in the location
indicated on page 2 of the form?

(Circle one) Yes No Conditional

If No or Conditional, please explain:

PERSON COMPLETING THE PHYSICAL EXAMINATION:

Name Position Date

Signature of Examining/Supervising Physician (not electronic:

___________________________________________________________________________________________Date: _______________

Name of Examining/Supervising Physician, incl. credential:_______________________________________________________________

Telephone #: _________________________________________Email address: _____________________________________________

Address:

PART IX: PARTICIPANT'S STATEMENT: To be Completed by Participant

I certify that I have reviewed the information entered in Parts I, II III, and IV and have discussed subsequently with a doctor,
physician or nurse practitioner the information in Parts VI, VII and VIII. This information is true and complete to the best of
my knowledge. I am aware that the information in this form and any attachments (e.g., laboratory test results, X-rays, etc.)
are being provided to my administrating agency as part of the medical clearance process.
I acknowledge that falsifying or knowingly excluding critical medical information may jeopardize my participation in this
educational exchange program. Furthermore, I understand that if any of this information is found to be substantially
inaccurate or incomplete, it may result in termination of my grant and result in my return home.
Prior to departure I understand that I must immediately notify Post or Fulbright Commission of any changes in my medical
status or overall health and wellness. During the grant, I must immediately notify the Institute of International Education (IIE)
of any change in my medical status.
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.

Signature (not electronic): Date:

Privacy Policy: The information provided by you and your physician(s) will remain confidential and will be responsibly shared with
appropriate professionals for grant administration purposes only.
Revision date: February 21, 2023
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