Ds 1622-2025

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The document is a medical history and examination form from the U.S. Department of State for children aged 11 and younger, aimed at assisting in medical clearance decisions for individuals participating in the Department's Medical Program while assigned abroad. It includes sections for demographic information, medical history questions, current medications, hospitalizations, and instructions for completion and submission. The form emphasizes the importance of providing accurate medical information and outlines privacy considerations under the Privacy Act.

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Click ‘Get Form’ to open the ds 1622 in the editor.
Begin by filling out the Demographic Information section. Enter the Name of Examinee, Date of Birth, Sex, and other required details accurately.
Proceed to the Medical History section. For each question, select 'Yes' or 'No'. If you answer 'Yes', provide a written explanation in the designated box.
List any current medications your child is taking in Section III. Be thorough and include all prescription and over-the-counter drugs.
Complete the Hospitalizations/Operations section by detailing any relevant medical history, including dates and types of procedures.
Ensure that all fields are filled out completely before signing on page 2. Review your entries for accuracy.
Submit your completed form via email in PDF format as instructed, ensuring all laboratory tests are attached.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (193 Votes)
2017	4.3 Satisfied (126 Votes)
2002	4.3 Satisfied (422 Votes)

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What happens during a medical clearance?

The medical clearance is based upon the employee participating in a complete head-to-toe physical examination, a complete blood panel, a health history questionnaire, an EKG, vision test, pulmonary function test, hearing test, and a stress test for those over the age of 40 or at the discretion of the provider.

How long does it take for a medical certificate?

How you can apply. If youre entitled to a certificate because of your medical condition, speak to your GP or doctor. Theyll give you an application form. Youll get a certificate in the post within 10 working days of us receiving your application.

How long does a medical clearance take?

Basic Evaluations: Without tests, it may take up to 12 days. Comprehensive Clearances: If lab tests or imaging studies are required, may take several days.

What is a foreign service medical clearance?

A medical clearance enables these individuals to access Department health care benefits and services while posted abroad. Benefits include, but are not limited to, access to the post Health Unit, medical evacuation travel, and secondary payer coverage for hospitalizations.

How long do medical clearances last?

In most cases, clearance is valid for 30 days, although this may vary depending on the surgical facility and your overall health.

Why does medical clearance take so long?

However, notice of the applicants medical status from the contracted clinic may take up to 10 business days from the date of the medical examination. In some cases, the process can be extended longer due to the need to review and consider additional information or personal medical records from the applicant.

What does a medical clearance consist of?

A medical clearance consists of a physicians go signal indicating that individuals are healthy enough with minimized risk before a certain activity or procedure. This evaluation form contains basic patient information and history, results of medical exams, and notes from past sessions.

Ds 1622-2025

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