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Instructions to Panel Physicians for Completing Medical History and Physical Examination Worksheet (DS-3026)
Please note: this page provides instructions for completing specific Department of State forms. The forms are not available on this website. Additional information about the forms is provided by the U.S. Department of State.
Each immigrant and refugee applicant must have a health assessment that includes
- Past medical history information
- A review of systems
- A physical examination
The Technical Instructions established these requirements (4). To aid in performing the health assessment in a systematic and reportable manner, a worksheet has been developed.
Complete the top section with the applicant's
- Name (last name, first name, and middle name)
- Date of the examination giving month, day, and year. This date may be different than the date that syphilis or HIV results are obtained
- Birth date giving month, day, and year
- Passport number
- Alien number, or case number if a refugee, whichever if available
A Class B condition is being defined as a condition (in the past medical history or current physical examination) that will require follow-up care for the well being of the individual. Past medical history conditions or physical examination findings that have no impact on an individual's current or future health and well being need not be noted.
Complete Sections 1 Through 5 on the DS-3026 Worksheet.
SECTION 1—Past Medical History
Ask about each disorder or behaviors and indicate the absence or presence of any of these disorders or behaviors by checking the corresponding "Yes" or "No" box.
The panel physician or a member of the physician's professional staff must review any available medical records of hospitalization (medical or psychiatric), other institutionalization, or outpatient visits according to the Technical Instructions. In addition, the panel physician or a member of the physician's professional staff must collect any past medical information reported by the applicant. The panel physician must determine whether the applicant has or has had any medical condition or mental disorder based upon these records and the applicant's reporting that will require medication or other type of treatment after resettlement (Class B), and indicate by checking the box "Yes" to the left of the condition that applies.
The section is divided into seven categories.
For the "General" category, the panel physician or a member of the physician's professional staff must determine if any hospitalization (medical or psychiatric) occurred that will require further medication or other type of treatment after resettlement, and indicate by checking the box "Yes" under the "General" category and to the left of any other condition that applies.
For the remaining categories—Cardiology, Pulmonology, Neurology and Psychiatry, Obstetrics and Sexually Transmitted Diseases, Endocrinology and Hematology, and Other—the panel physician or a member of the physician's professional staff must collect this information. The majority of the medical conditions are straightforward; they are specifically mentioned because any of them may require medication or other treatment after the applicant resettles. To minimize any future complications, these conditions must be noted so that the need for follow-up care can be recognized.
For Neurology and Psychiatry conditions, if there is a possibility of any mental disorder that could potentially be a Class A condition, a psychiatric referral is recommended.
For "Major mental disorders" at a minimum ask about—major depression, bipolar disorder, schizophrenia, and mental retardation. These disorders, according to the Diagnostic and Statistical Manual of Mental Disorders (5) are defined as
- Major depression—The presence, during 2-week period occurring almost daily, of the following primary symptoms: (1) Depressed mood (such as reporting being sad or empty, or appearing tearful); (2) Marked decrease in interest or pleasure in all, or almost all activities; or both.
In addition, the applicant must have three of four of the secondary symptoms, depending on whether one or both of the primary symptoms are present:- Significant weight change,
- Abnormal sleep pattern (insomnia or hypersomnia),
- Excessive restlessness or inactivity,
- Excessive fatigue or loss of energy,
- Feelings of worthlessness or excessive guilt,
- Inability to think or concentrate, nearly every day, or
- Recurrent thoughts of death or suicide attempt.
- Bipolar disorder—The presence of manic or hypomanic episode(s), with or without episodes of depression in between, defines bipolar disorders.
A manic episode is the presence of abnormal and persistent elevated, expansive, or irritable mood for at least 1 week. The mood disturbance must have three or more of the following symptoms:- Inflated self-esteem or grandiosity.
- Decreased need for sleep (only sleeping for 3 hours).
- Talking more than usual.
- Flight of ideas or the feeling that thoughts are racing.
- Distractibility (attention easily drawn to unimportant external stimuli).
- Increased goal-directed activity (at work or school, socially or sexually) or psychomotor agitation.
- Excessive involvement in pleasurable activities that might have painful consequences (such as unrestrained spending or sexual indiscretion).
A manic episode causes marked impairment in work or social activities or relationships, or required hospitalization, and is not because of medication or hyperthyroidism.
In contrast, a hypomanic episode has symptoms of mania (see below) lasting a shorter time period (4 days or more), but without impairing work or social activities or relationships.
- Schizophrenia or related disorders—The presence, for a significant portion of time during a 1-month period, of two or more of the following symptoms:
- Delusions.
- Hallucinations.
- Disorganized speech (such as frequently incoherent).
- Grossly disorganized or catatonic behavior.
- Negative symptoms (such as being withdrawn, not speaking, or have a loss of will, drive, or activity).
Schizophrenia is also associated with 6 months of residual symptoms and decreased functioning in at least one major social or occupational area, such as work, interpersonal relations, or self-care as compared to functioning at onset. These symptoms and poor functioning cannot be because of major depression or medication.
In contrast, other related disorders have the same symptoms, but without accompanying decrease in functioning and for less time.
- Mental retardation—Significantly subaverage intellect (such as an intelligence quotient [IQ] of 70 or below, or for infants, a clinical judgement of such) in a person with onset before 18 years of age, plus deficits or impairments (compared with others of his or her age and cultural group) in two or more of the following areas:
- Communication
- Self-care
- Home activities
- Social or interpersonal skills
- Use of community resources
- Self-direction
- Educational skills
- Work
- Leisure activity
- Health
- Safety
If any of these disorders is associated with:
- "Ever causing SERIOUS injury to others, causing MAJOR property damage or having trouble with the law because of medical condition, mental disorder, or influence of alcohol or drugs," or
- "Ever taken action to end your [the applicant's] life,"
then the disorder is associated with harmful behavior and is a Class A condition.
Other disorders that may be associated with harmful behaviors include personality disorders and, in particular, antisocial personality disorder and paranoid personality disorder with harmful behavior towards others. Antisocial personality disorder is a pervasive pattern of disregard for violation of the rights of others occurring since 15 years of age, but not diagnosed until age 18 years. The presence of three or more of the following indicate this disorder:
- Failure to conform to social norms and laws
- Deceitfulness and lying
- Impulsiveness or failure to plan for the future
- Physical fighting and assaults
- Reckless disregard for the safety of self or others
- Repeated job or financial failures
- Lack of remorse after hurting or steeling from others
Borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and marked impulsiveness beginning in early adulthood and is often associated with recurrent suicidal behavior.
Likewise, if "Addiction (dependence) or abuse" to any of the controlled substances in the United States of the classes of "amphetamines, cannabis, cocaine, hallucinogens, inhalants, opioids, phencyclidines, sedative-hyponotics, or anxiolytics," is present, this is a Class A condition.
Addiction and abuse, according to the Diagnostic and Statistical Manual of Mental Disorders (5), are defined as
- Dependence (addiction)—A maladaptive pattern of substance use, leading to three or more of the following, occurring at any time in the same 12-month period:
- Tolerance (a need for increasing amounts of a substance to achieve intoxication or a desired effect, or a markedly decreased effect with the same amount of substance).
- Withdrawal (characteristic symptoms, or social- or work-related distress or impairment when stopping substance use).
- Taking of the substance in larger amounts or for longer periods than was intended.
- A persistent desire or unsuccessful efforts to control the substance use.
- Spending a lot of time obtaining the substance, using the substance, or recovering from its effects.
- Continued use of the substance despite knowing a persistent or recurrent physical or psychological problem is caused or exacerbated by the substance (such as continued alcohol drinking despite having an ulcer).
- Abuse—A maladaptive pattern of substance use leading to one or more of the following:
- Recurrent use resulting in impairment at work, school, or home (such as repeated absence or poor work performance, expulsion from school, or neglect of children or household).
- Recurrent use when physically hazardous (such as while driving a car or operating machinery).
- Recurrent substance-related legal problems (such as arrests for substance-related disorderly conduct or recurrent positive urine toxicological testing as a part of the migration health assessment).
- Continued use despite persistent or recurrent social or interpersonal problems (such as arguments with spouse about actions while intoxicated, or physical fights).
Other substance-related disorders include alcohol addiction (dependence) or abuse. It these disorders are associated with harmful behavior such as driving under the influence of alcohol, domestic violence or other alcohol-associated criminal behavior, they are Class A conditions.
For Obstetrics and Sexually Transmitted Diseases, if a female applicant is pregnant check the box to the left on "Pregnant." Determine her "Fundal height," which is the distance in centimeters between the symphysis pubis (midline of the pelvic bone) and the top of the fundus (uterus), and roughly equals the gestational weeks after 20 weeks of gestation. It is important to know this as well as the date of the last menstrual period to determine a safe travel period.
Likewise, history of "Sexually transmitted diseases" is a risk factor for current diseases and an important history to obtain. If any sexually transmitted diseases (STDs) existed in the past check the "Yes" box to the left. Infectious syphilis, chancroid, gonorrhea, granuloma inguinale, and lymphogranuloma venerum are STDs that must be treated before the refugee or immigrant applicant can come to the United States.
For Endocrinology and Hematology, "History of malaria" may be empirically diagnosed or laboratory confirmed. In either case (empiric or laboratory confirmed), please indicate which type of diagnosis and give any details in the "Other requiring treatment, specific" row.
For Other, "Hansen's Disease" or leprosy is an infection caused by Mycobacterium leprae and associated with anesthetic skin lesions, peripheral nerve enlargement, and the finding of acid-fast bacilli in skin or nerves. Over a course of years, the person infected may develop skin lesions that vary from pale to dark red, from flattened to raised, and from obvious to almost invisible. Skin lesions typically affect the cooler parts of body (legs, arms, ears and nose) are associated with loss of sensation to soft touch, temperature, and finally pain. Enlargement of peripheral nerves is found and may be associated with anesthesia initially, followed by motor loss and muscle wasting.
Hansen's Disease is classified following skin biopsy or slit skin smears performed after examining the patient's skin and peripheral nerves. The patient's histopathology is then classified using the Ridley-Jopling or World Health Organization (WHO) classification systems.
- Tuberculoid—One or few lesions found; may be asymmetrical; lesion tends to be flat and hypopigmented; associated with anesthesia and peripheral nerve enlarged in same body region; few or no acid-fast bacteria seen on skin smear or biopsy.
- Lepromatous—Widely disseminated skin infection that appears indistinct and generalized. Lesions have vague edges and may appear swollen or thickened. Peripheral nerves are less involved. Anesthesia found in distal hands and feet in "stocking-glove" pattern with longstanding infection. Numerous bacteria are seen in skin smears or biopsy.
- Borderline—Unstable midline between tuberculoid and lepromatous. Skin lesions may be few or many, and may be generalized over body. Lesions tend to be bright red and have clear sharp edges. Normal appearing skin may be seen in center of lesions (particularly if very large) surrounded by red borders. Nerve involvement can be widespread and rapidly damaging. Presence of bacteria in skin is variable.
OR
- Paucibacillary—Infection of the Tuberculoid variety. Few or even no bacteria are seen on skin smear or biopsy.
- Multibacillary—Infection of the Lepromatous variety, with numerous bacteria seen in smear or biopsy.
Treated—People receiving leprosy treatment for as little as one week can no longer transmit the bacteria to others. Treatment may be required for up to 2 years to successfully eliminate the infection from a person's body. Incomplete or erratic therapy is associated with relapse of infection, development of resistance to medication, and progressive debilitation from Hansen's Disease.
For the row of Visible disabilities, include such as history of scoliosis requiring follow-up care.
For Other requiring treatment, include such as history of peptic ulcer disease requiring treatment.
SECTION 2—Physical Examination
Each applicant, regardless of age, must undergo a physical examination performed by the panel physician.
While obtaining the past medical history and performing the physical examination, the panel physician must determine if the "Applicant appears to be providing unreliable or false information." If the applicant appears to be forthcoming with all of his or her answers, check the first box to the left of the statement for "No." If the applicant's answers appear to be unreliable, check the second box to the left of the statement for "Yes." If "Yes" is checked, explain why.
Measurements of height and weight, vital signs, and visual acuity should be performed at a minimal for the following groups:
Children:
- Height in centimeters (cm) and
- Weight in kilograms (kg) should be recorded.
Adults, especially the elderly or anyone with a history of Cardiac or Pulmonary conditions:
- Blood pressure (BP) in millimeters of mercury (mmHg),
- Heart rate per minute (/min), and
- Respiratory rate per minute (/min) measurements should be obtained.
Children (once they are cooperative with the examination) or anyone with apparent visual problems:
- Visual Acuity at 20 feet, using a wall chart such as Snellen's, should be obtained in each eye (left eye at 20 feet [L 20/_____] and right eye at 20 feet [R 20/_____]. If the applicant wears corrective lenses (glasses or contact lenses), the visual acuity may be obtained with correction in place and so indicated by placing results in the Corrected row. If the applicant does not wear corrective lenses, place results in the Uncorrected row.
For the physical examination, mark N for normal, A for abnormal, and ND for not done (not examined) for each body part examined. If an abnormality exists with one of the terms in the parenthesis following the body part, circle that term.
At the minimum for all applicants, the physical examination must include examination (4) of the
- Hearing and ears—Check hearing, such as the applicant's ability to hear fingers rubbed together for each ear.
- Eyes—Examine the conjunctiva, check the red reflex in young children, and perform a fundoscopic examination in applicants with Cardiac or Endocrine conditions.
- Nose, mouth, and throat—Examine the nose and throat for signs of infection (enlarged tonsils or erythema) and include the condition of the teeth [dental condition]). If there are caries, circle dental.
- Heart—Examine all applicants to assess the heart sounds (S1 and S2), the rhythm, and for the presence of a murmur or rub. If either present, circle which is present, murmur or rub.
- Lungs—Examine for signs of consolidation, such as dullness on percussion, or rales or bronchial breath sounds on auscultation. Check for evidence of pleural effusion, such as dullness and decreased air entry on percussion, and decreased tactile vocal fremitus. Indicate abnormal sound to the right of Lungs.
- Abdomen—Palpate the abdomen assessing the size of the liver and spleen. If the liver or spleen is enlarged, circle which is enlarged, liver or spleen.
- Genitalia—Examine the external genitalia of both male and female applicants assessing for signs of "Sexually transmitted diseases" and prior circumcision in both male and female applicants. If circumcision is present, circle circumcision. If signs of infection are present (such as discharge or lesion), circle infection.
- Inguinal region—Palpate the inguinal region for adenopathy (enlarged lymph nodes), which may be a sign of "Sexually transmitted diseases." If adenopathy is present, circle adenopathy.
- Extremities—Palpate the extremities for presence of pulses (especially posterior tibial and dorsalis pedis) and edema. If pulses are diminished, circle pulses. If edema is present, circle edema.
- Skin—Examine the skin for signs of Hansen's disease (flat and hypopigmented lesions associated with anesthesia of the region, to lesions with vague edges that may appear swollen or thickened, to lesions tending to be bright red with clear sharp edges), findings consistent with self-inflicted injury (such as linear scars at wrist), and findings consistent with injections (such as puncture scars in the antecubital region of the arm). If any of these findings are present, circle the finding.
- Lymph nodes—Examine at least the neck and armpit for enlarged lymph nodes or adenopathy. Indicate the area of body where adenopathy is present to the right of Lymph nodes.
- Mental status—At the minimum, each applicant must be assessed for mood, intelligence, perception, thought processes, and behavior as a part of the examination. Formal psychological testing is not required and rarely helpful even in cases of possible Class A mental disorders. If any of the states is found to be abnormal, circle the abnormal state.
In addition, the applicant's "General appearance and nutritional status" should be assessed for degree of development, signs of malnutrition or obesity, or for dehydration. For all female applicants, a "Breast" examination should be performed assessing for the presence of masses or discharge. Performing a routine musculosketelal examination, looking at tone and strength, should be done to assess the "Musculoskeletal system". In addition, include an assessment of the applicant's gait. If the gait is abnormal, circle gait. Also examine the nervous system by examining the body for normal neurologic function. In addition, examine the body for nerve enlargement, a sign associated with Hansen's disease. If nerve enlargement is present, circle nerve enlargement.
For a panel physician of the opposite sex of the applicant, an assistant of the same sex as the applicant should be present for breast examinations (for women) and examination of external genitalia. Gowns for women should be provided during the physical examination.
All areas of the body examined must be indicated by checking the corresponding box for "N" (normal), "A" (abnormal), or "ND" (not done), noting that the examination must include
Numbers 1 through 12 at a minimum as indicated in the Technical Instructions (7).
SECTION 3—Additional Testing Needed Prior to Approving Medical Clearance
After performing the physical examination and reviewing the laboratory results, the panel physician must determine if the "Physical examination or laboratory results contradict medical history." If all (past medical history, physical examination, and laboratory results) appear to agree, check the first box to the left of the statement for "No." If there are findings and results that contradict the applicant's past medical history, check the second box to the left of the statement for "Yes." If "Yes" is checked and explain why.
Use this section to record any additional tests performed prior to the applicant's departure, either initial referrals to outside consultants (Referral prior to departure. If yes, provide results) or reevaluations by the panel physician (Reevaluation prior to departure. If yes, provide results) according to the Technical Instructions. If either is performed, check the second "Yes" box and give details. If no further work-up was needed, check the first "No" box for each.
SECTION 4—Follow-up Needed After Arrival and SECTION 5—Remarks
These sections are to indicate if follow-up is needed after resettlement in the United States according to the Technical Instructions, and how soon after resettlement. If any box other than "No" is checked, review the condition or finding with the applicant and describe the condition or finding in SECTION 5—Remarks.
In addition, if any of the conditions or findings noted during the Past medical history or Physical examination needs follow-up after resettlement and is not listed on the DS-2053, write it in the "Other" row under Class B Conditions on DS-2053.
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