Medical History and Physical Examination

Technical Instructions for the Medical Examination of Aliens in the United States

Table Of Contents

Preface

• Medical History and Physical Examination
  1. Scope of the Examination
  2. Management of Medical Conditions not Related to the Medical Exam
  3. Referral for Further Evaluation
  4. Medical Report Form

Preface

The Centers for Disease Control and Prevention (CDC), United States Public Health Service (PHS), is responsible for ensuring that aliens entering the United States do not pose a threat to the public health of this country. The medical examination is one means of evaluating the health of aliens applying for admission or adjustment of status as permanent residents in the United States.

These instructions are for the use of civil surgeons and U.S. Department of Homeland Security (DHS) officials who are evaluating aliens applying for adjustment of status to permanent resident, as well as for any other alien required by DHS to have a medical examination. This document supersedes the June 1985 Guidelines for Medical Examination of Aliens in the United States.

Medical History and Physical Examination

A. Scope of the Examination

The purpose of the medical examination is to determine whether the alien has: 1) a physical or mental disorder (including a communicable disease of public health significance or drug abuse/addiction) that renders him or her ineligible for admission or adjustment of status (Class A condition); or 2) a physical or mental disorder that, although does not constitute a specific excludable condition, represents a departure from normal health or well-being that is significant enough to possibly interfere with the person’s ability to care for him- or herself, to attend school or work, or that may require extensive medical treatment or institutionalization in the future (Class B condition).

1. The medical examination requires
   1. A medical history, obtained by the civil surgeon or a member of the physician’s professional staff, from the applicant (preferably) or a family member, which includes
      1. a review of all hospitalizations
      2. a review of all institutionalizations for chronic conditions (physical or mental)
      3. a review of all illnesses or disabilities resulting in a substantial departure from a normal state of well-being or level of functioning
      4. specific questions about psychoactive drug and alcohol use, history of harmful behavior, and history of psychiatric illness not documented in the medical records reviewed and
      5. a review of chest radiographs and treatment records if the alien has a history suggestive of tuberculosis
   2. A review of any other records that are available to the physician (e.g., police, military, school, or employment) that may help to determine a history of harmful behavior related to a physical or mental disorder and to whether illnesses or disabilities are present that result in a substantial departure from a normal state of well-being or level of functioning.
   3. A review of systems sufficient to assist in determining the presence and the severity of Class A or Class B conditions. The physician should ask specifically about symptoms that suggest cardiovascular, pulmonary, musculoskeletal, and neuropsychiatric disorders. Symptoms suggestive of infection with any of the excludable communicable diseases (tuberculosis, syphilis, gonorrhea, and Hansen’s disease) should also be sought.
   4. A physical examination, including an evaluation of mental status, sufficient to permit a determination of the presence and the severity of Class A and Class B conditions. The physical examination is to include
      1. a mental status examination that includes, at a minimum, assessment of intelligence, thought, cognition (comprehension), judgment, affect (and mood), and behavior
      2. a physical examination that includes, at a minimum, examination of the eyes, ears, nose and throat, extremities, heart, lungs, abdomen, lymph nodes, and skin
      3. all diagnostic tests required to identify communicable diseases of public health significance, as well as other tests identified as necessary to confirm a suspected diagnosis of any other Class A or Class B condition

B. Management of Medical Conditions not Related to the Medical Exam

The responsibility of the civil surgeon is only to conduct the examination and testing required to determine the alien’s status regarding Class A and Class B conditions and to complete the medical report form. If the examination reveals an acute illness that makes it impossible to determine the alien’s medical status regarding Class A or B conditions, the acute illness should be treated by a physician of the alien’s choice, and the medical examination process completed when the alien has recovered. If the alien needs further evaluation or treatment for conditions not relevant to the medical examination, the physician should advise the alien of this and should make recommendations for appropriate diagnostic evaluation and treatment.

C. Referral for Further Evaluation

In some instances, the civil surgeon may be unable to make a definitive diagnosis or to determine whether a disease or disorder is a Class A or a Class B condition. In such instances, the civil surgeon must refer the alien for a medical or mental health evaluation that will provide sufficient information to resolve the uncertainties of either diagnosis or Class A or Class B designation. The civil surgeon remains responsible for completing and forwarding the medical report form to the DHS official. The report of the consulting physician, as received by the civil surgeon, must be included with the medical report form.

D. Medical Report Form

1. The medical report form is to be completed in English, typed, dated, and signed by the civil surgeon.
2. The results of required tests for tuberculosis and syphilis must be entered in the appropriate spaces on the medical report form.
3. Findings of physical and mental disorders should be entered in the “Remarks” section of the medical report form. The civil surgeon must include a statement of likely degree of disability and the need for extensive medical care or institutionalization for any Class B conditions identified during the examination.
4. Findings of drug abuse or addiction should be indicated in the “Remarks” section of the medical report form. The civil surgeon should indicate the specific drug that is/was being used and the last time it was used if the patient has discontinued its use.

NOTE: If an alien has been referred for further evaluation under the provisions of III A, B, C, or D, the medical report must not be completed and submitted to the INS officer until a definitive diagnosis (or a short list of likely diagnoses) and the presence or absence of a Class A or Class B condition has been established.