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Fillable Printable Form DS-6561

Fillable Printable Form DS-6561

Form DS-6561

Form DS-6561

8. Post of Assignment and Estimated Dates of Arrival / Departure
(if known)
9. Details of Assignment (Check all that apply)
DS-6561
07-2017
To the individual and/or health care provider completing the medical history review /exam: The Genetic
Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title
II from requesting or requiring genetic information of an individual or family member of the individua l , except as
specifically allowed by this law. To comply with this law we are asking that you NOT provide any genetic
information when responding to this request for medical information. 'Genetic Information' as defined by GINA,
includes an individual's family medical history, the results of an individual's or family members' genetic tests,
the fact that an individual or an individual's family member sought or received genetic services, and genetic
information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an
individual or family member receiving assistive reproductive services.
Page 1 of 4
a. Proposed Post:
b. Present Post:
EDD
(mm-dd-yyyy)
EDA
(mm-dd-yyyy)
Frequent TDY
Iraq
AFG
Other ESCAPE Post/Name:
Other:
11. Telephone number of examinee or parent of child < 18 y/o
(Where you can be reached for the next 90 days)
10. Email Address of examinee or parent of child < 18 y/o
(Where you can be reached for the next 90 days)
PRIVACY ACT STATEMENT
AUTHORITIES: The information is sought pursuant to the Foreign Service Act of 1980, as amended (Title 22 U.S.C.4084).
PURPOSE: The information solicited on this form will be used to make appropriate medical clearance decisions.
ROUTINE USES: Unless otherwise protected by law, the information solicited on this form may be made available to appropriate agencies, whether
Federal, state, local, or foreign, for law enforcement and other authorized purposes. The information may also be disclosed pursuant to court order.
More information on routine uses can be found in the System of Records Notice State-24, Medical Records.
DISCLOSURE: Providing this information is voluntary; however, not providing requested information may result in the failure of the individual to obtain
the requisite medical clearance pursuant to 16 FAM 211.
OVERSEAS PRE-ASSIGNMENT MEDICAL HISTORY AND EXAMINATION
Non-Foreign Service Personnel and Their Family Members
OMB APPROVAL NO. 1405-0194
EXPIRATION DATE 07/31/2020
ESTIMATED BURDEN: 1 HOUR*
PAPERWORK REDUCTIO N ACT STATEMENT: Public reporting burden for this collection of information is estimated to average one (1) hour 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 recommendation for reducing it, please send them to:
M/MED/EX, Room L101 SA-1, U.S. Department of state, Washington, DC 20522
U.S. Department of State
Bureau of Medical Services, M/MED, Room L101, SA-1, Washington, DC 20522- 0102
I. DEMOGRAPHIC INFORMATION
TO BE FILLED OUT BY EXAMINEE (OR PARENT for EXAMINEE < 18 Y/O)
DATE OF EXAM(mm-dd-yyyy)
1. Name of Examinee (Last, First, MI)2. If Eligible Family Member, Name of Employee:
3. U.S. Govt. Agency and Branch:5. Sex4. Date of Birth (mm-dd- yyyy)
Male
Female
6. Status
SpouseDependent ChildEmployee
Domestic Partner
7. EMPLOYMENT STATUS:
Civil ServiceWAE
PSC Contractor / Bureau or Office:
DOD Contractor
Locally Engaged StaffDOD Civilian
Contractor (include name of contracting company and assoc. USG Agency):
LNAOther:
For all applicants, employees or eligible family members::
39. Is there any other medical or mental health condition not covered in questions 1 - 38? Explain:
III. LIST OF CURRENT MEDICATIONS (Include prescription, over the counter, vitamins, and herbs)Drug Or Other Allergies
IV. HOSPITALIZATIONS/OPERATIONS/MEDICAL EVACUATIONS (Include all medical and psychiatric illnesses)
Date (mm-dd-yyyy)
Illness or Operation
Name of Hospital
City and State
IIA. Explanations required for "Yes" answers to questions 1-39. Attach additional sheets as needed.
YesNo
Page 2 of 4
Children Only: 34. Has your child been referred for any current or potential special educational services, accommodations,
or modifications (i.e.: IFSP, Early Intervention, IEP, 504 Plan)? Explain:
Women: (provide results if applicable, N/A if not applicable)
35. Date of last PAP test? Results:
36. Date of last Mammogram? Results:
Are you pregnant? Est. due date:
YesNo
IN THE PAST SEVEN (7) YEARS (for questions 29-33)
(parents - please answer for children < 18 years of age)
29. Have you used marijuana, amphetamines, narcotics,
cocaine, or hallucinogenic drugs?
30.Have you been in psychotherapy/counseling or been
prescribed medication for depression, anxiety, mood or stress?
31. Have you felt unusually depressed, sad, blue, or had
frequent crying spells which lasted more than two weeks at a time?
32. Have you had frequent or recurrent episodes of:
difficulty in relaxing or calming down, panicky feelings, irritability, anger,
feeling hyper, or nervousness?
Name of Examinee
Do you (or your child) have a hisory of:
(parents - please answer for children < 18 years of age)
Yes
1. Frequent/severe headaches or migraines?
2. Fainting or dizzy episodes?
No
3. Stroke, TIA or head injury?
4. Epilepsy, seizures or other neurologic disorders?
5. Chronic eye or vision problems?
6. Ear, nose, throat problems; hearing loss, hoarseness?
7. Allergies or history of anaphylactic reaction?
8. Shortness of breath, asthma, or COPD?
9. History of abnormal chest x-ray?
10. History of positive TB skin test or tuberculosis?
11. Aneurysm, blood clot or pulmonary embolism?
12. High blood pressure?
13. Heart problems, murmur or palpitations?
14. Have you smoked any cigarettes in the last month?
15. Stomach, esophageal, intestinal problems?
16. Jaundice or hepatitis (type)?
17. Intestinal, rectal problems or hernia?
18. Urinary or kidney problems, blood in urine?
19. Diabetes or thyroid disorder?
20. Joint or back pain/injury?
DOB
II. MEDICAL HISTORY
PLEASE ANSWER THE FOLLOWING QUESTIONS: For YES answers, provide a brief explanation, attach additional sheets, if needed.
28. Have you consumed at any one time in the past year,
more than 5 alcohol drinks for males or 4 drinks for females? Explain.
21. Rheumatologic disorder?
Yes
22. Anemia?
No
23. Blood transfusion?
24. Malaria or other tropical disease?
25. Any skin or nail disorder?
26. Cancer of any type?
27. Any thickening or lump in breast, testicle?
Date (mm-dd-yyyy)
V. SIGNATURE OF EXAMINEE OR PARENT OF CHILD <18 Y/O (I certify I have read and understand the above statement.)
Any knowing and willful omission, falsification, or fraudulent statement regarding material medical information may constitute a criminal
offense under 18 U.S.C. § 1001, and individuals committing such an offense may be subject to criminal prosecution. Employees of the
United States Government also may be subject to disciplinary action, up to and including separation, for any knowing and willing omission
or falsification or fraudulent statement of material information.
33. Have you experienced any emotional or physical
symptoms related to a past trauma?
YesNo
DS-6561
Men/Women: Colon Cancer Screening:
(provide results if applicable, N/A if not applicable)
38. Date of last colon cancer screening, if applicable:
Test (colonoscopy/sigmoidoscopy/guiacFOBT):
Results:
YesNo
DS-6561
Page 3 of 4
Name of ExamineeDOB
V. INSTRUCTIONS FOR COMPLETION AND SUMBISSION OF FORM DS-6561
MEDICAL EXAMINER
• Medical Examiner must comment on positive history on page 2. Medical Examiner must comment on physical findings and provide
recommendations for treatment/further study/consultations of medical & mental health problems.
• Medical Examiner must sign on page 4.
EXAMINEE / SPONSOR / PARENT
• All fields on page 1 and 2 must be filled out. Examinee or parent/employee sponsor must sign on page 2.
• Submit copies of all laboratory tests and additional medical reports with DS-6561.
• All Lab tests and medical reports must be in English, and identified with full name and date of birth of examinee.
• Keep originals as a permanent record. Do NOT submit by U.S. Mail or by courier service (e.g. FedEx or DHL). The preferred method to submit
the DS - 6561 (and supporting documentation) is to scan and email in PDF format to: MEDMR@state.gov. If it is not possible to scan, please fax to
Medical Records department FAX: 703-875-4850. If you wish to confirm that your exam forms were received, please email MEDMR@state.gov.
Notes
(Describe every abnormality in detail.
Include pertinent item number before each comment.)
VII. Clinical Evaluation
Check each item as indicated.
Check "NE" if not evaluated.
NormalAbnormalNE
1. General/Constitution
1. Height4. Pulse5. Blood Pressure (sitting)
If above 140/85 repeat 3 times and record.
2. Weight
lbs. or
kgs
in. or
cm.
VII: Clinical Evaluation: Newborn exam cannot be accepted if completed before four (4) weeks of age
2. Mental / Affect / Mood / (Development-children)
3. Skin
4. Eye
5. Ears/Nose/Throat
6. Neck/Thyroid
7. Lungs/Thorax
8. Breasts
9. Cardiovascular
(Record murmurs/abnormalities)
10. Abdomen
11. Male Genitalia
12. Anus/Rectum/Prostate (if indicated)
13. Musculoskeletal / Spine / Extremities
(Note limitations)
14. Lymph Nodes
15. Neurologic
16. Female Gynecologic (if indicated)
3. BMI
VI: Medical Examiner comments on significant patient medical history and items checked "yes" on page 2/section II. Use additional pages,
if needed.
1a. Hematology :
Ages 12 years and older
Hematocrit %
or
Hemoglobin gms%
WBC /cmm
Platelets
3. Serology
Ages 12 years and older
HIV I/II Antibody
2. Chemistry
Ages 12 years and older
Fasting Blood Sugar
HgA1C (if indicated)
Creatinine
ALT
1. Hematology:
Ages 1 year to 11 years
Hematocrit %
or
Hemoglobin gms%
4. Tuberculin Skin Test: Required for ages 1 and over (unless previously positive) 5. Chest X Ray (PA and lateral) - submit report
• Required for those with > 10 mm TST newly identified
or if positive IGRA
OR
• When clinically indicated
Results: mm of induration Date:
Interferon Gamma Release Assay: (may substitute for TST if > 5 y/o or
In those with previous BCG)
Results:
Date:
If no TB screening performed, explain why:
Previous active tuberculosis
Previous positive TST or IGRA
Previous LTBI treatment
Hx of BcG vaccine
Other:
NoYes
NoYes
NoYes
NoYes
Date:
Date:
Date:
Date:
Results: Date:
DS-6561Page 4 of 4
Name of ExamineeDOB
6. ECG (50 years or older, earlier if indicated) - submit tracing
Results:
Date:
OPTIONAL TESTS: The following tests may be performed at the discretion of the Examiner, with patient consent. They are not required for a medical
clearance determination. If performed, results may be used in the provision of care to individuals covered under the Department of State Medical
Program.
X. Assessment or Problem ListXI. Recommendation for Treatment / Further Study / Consultation or
Follow - Up
7. Blood Type ( if not previously documented)
Type: ABO
(weak D):
8. G6PD (If not previously documented) for malarial prophylaxis
Results:
Date:
9. Blood lead level (recommended screening ages 12 months to 5 years)
Results:
Date:
(Rh) Dµ:
IX. LABORATORY ANALYSIS: All tests are required unless otherwise specified. Test results from previous 12 months are acceptable.
COPIES OF LABORATORY REPORTS MUST BE SUBMITTED FOR REVIEW AND MUST BE IN ENGLISH
Signature of Examiner
Typed Name of ExaminerDate (mm-dd-yyyy)
Telephone NumberExamining Facility
Address
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