DS-3026 Medical History and Physical Examination Worksheet-2025

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The document is a medical examination report form (DS-2054) used by the U.S. Department of State for visa applicants. It collects personal information, medical history, and vaccination status to assess eligibility for U.S. visas. The form includes classifications for various health conditions and emphasizes confidentiality regarding the information provided.

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Click ‘Get Form’ to open the DS-3026 Medical History and Physical Examination Worksheet in the editor.
Begin by filling in your personal information, including surnames, given names, birth date, sex, and contact details. Ensure accuracy as this information is crucial for your medical examination.
Next, provide details about your residency history. Fill in your birthplace, current country of residence, prior country of residence, and present address. This section helps establish your background.
In the applicant category section, mark the appropriate box that applies to you (e.g., Immigrant Visa, Refugee). This classification is essential for processing your application correctly.
Complete the medical history section by checking all applicable conditions. Be thorough in marking any Class A or Class B conditions as this impacts your eligibility.
Finally, ensure that the panel physician signs and dates the form after completing the examination. This signature validates your medical assessment.

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Versions	Form popularity	Fillable & printable
2020	4.2 Satisfied (47 Votes)
2011	4.2 Satisfied (34 Votes)

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What is required in an HP?

We always complete a formal HP on a new patient in the office and for admission to the hospital; it is required. Although it is called History and Physical, it includes an assessment and plan. The assessment may be a differential diagnosis, a list of symptoms, or a problem list.

What types of information make up a complete history and Physical?

A comprehensive history intake includes the patients medical history, past surgical history, family medical history, social history, allergies, and medications.

When must a medical history and physical examination be performed?

The medical history and physical examination must be placed in the patients medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.

What information must be included in the history and physical examination?

The HP: History and Physical is the most formal and complete assessment of the patient and the problem. HP is shorthand for the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending.

What information is included under physical assessment in an admission history and Physical?

Assessment findings that include current vital signs, lab values, changes in condition such as decreased output, cardiac rhythm, pain level, and mental status, as well as pertinent medical history with recommendations for care, are communicated to the provider by the nurse.