(MUST be completed and signed by applicant prior to medical exam)
ALIEN NUMBER If applicable
VISA CATERGORY If known
Legal Last Name
*
Legal First Name
*
Legal Middle Name (If any)
Date of Birth
*
/
Month
/
Day
Year
Date
Age
*
Gender
*
Birthplace (City/Country)
*
Nationality
*
Prior Country
*
Occupation
Full Current Mailing Address, Including Zip Code
*
Telephone
*
Format: (000) 000-0000.
Email
*
example@example.com
Do you require a translator? (Please note we do not provide a translator and if you require one, you need to have someone physically present with you that is fluent in both your native language and English)
*
YES
NO
Have you ever had a previous medical exam for Immigration purposes?
*
YES
NO
Have you ever been hospitalized? (Including Psychiatric Admission)
*
YES
NO
Have you ever had treatment or been worked up for TB (Tuberculosis) or been in contact with anyone that has TB?
*
YES
NO
Have you ever had any mental disorder or depression?
*
YES
NO
Have you ever used drugs?
*
YES
NO
Have you ever had an addiction to or abused alcohol?
*
YES
NO
Have you had any for of treatment or investigation for alcohol or drug abuse?
*
YES
NO
Have you ever been arrested, convicted, or received a warning for any drug or alcohol offense (Including Driving) anywhere in the world?
*
YES
NO
Have you ever caused deliberate injury to yourself or others?
*
YES
NO
Do you take any Medications? (Please List all Medications Below)
*
YES
NO
Please list your Medications Here:
If you have any additional comments or answered Yes to any questions above please provide further details here.
Do you have records to submit?
Please Select
YES
NO
Please attach any vaccine or medical records you may have available that can assist us with your exam.
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