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About Immigration Medical Exam
Expect During Your Exam
FAQ’s Virtual Physical
Report of Immigration Medical Examination and Vaccination Record
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Home
About Immigration Medical Exam
Expect During Your Exam
FAQ’s Virtual Physical
Report of Immigration Medical Examination and Vaccination Record
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Home
About Immigration Medical Exam
Expect During Your Exam
FAQ’s Virtual Physical
Report of Immigration Medical Examination and Vaccination Record
Menu
Home
About Immigration Medical Exam
Expect During Your Exam
FAQ’s Virtual Physical
Report of Immigration Medical Examination and Vaccination Record
Report of Immigration Medical Examination and Vaccination Record
Part 1: Information About You (To be completed by the person requesting a medical examination, NOT the civil surgeon.)
Family Name (Last Name)
Given Name (First Name)
Middle Name (if applicable)
Street Address
Apartment, suite, etc
City
State/Province
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China, People's Republic of
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French South Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Island
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Johnston Island
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion Island
Romania
Russia
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre & Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and South Sandwich
Spain
Sri Lanka
Stateless Persons
Sudan
Sudan, South
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan, Republic of China
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America (USA)
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna Islands
Western Sahara
Yemen
Zambia
Zimbabwe
Gender
Male
Female
Date of birth
City/Town/Village of Birth
Country of Birth
Alien Registration Number (A-Number) (if any)
USCIS Online Account Number (if any)
Part 2. Applicant's Statement, Contact Information, Certification, and Signature
Applicant's Contact Information
Provide your daytime telephone number, mobile telephone number (if any), and email address (if any).
Applicant's Mobile Telephone Number (if any)
Applicant's Mobile Telephone Number (if any)
Applicant's Email Address (if any)
Form of Identification Presented by Applicant (for example, passport or driver’s license)
Document Identification Number
CLIENT VACCINATION HISTORY
MMR
MMR
Yes
No
Not sure
Date
Note
Flu Shot
Flu Shot
Yes
No
Not sure
Date
Note
Covid
Covid
Yes
No
Not sure
Date
Note
Varicella
Varicella
Yes
No
Not sure
Date
Note
Td/Tdap
Td/Tdap
Yes
No
Not sure
Date
Note
Tuberculosis ( blood test)
Tuberculosis ( blood test)
Yes
No
Not sure
Date
Note
Syphilis (blood test)
Syphilis (blood test)
Yes
No
Not sure
Date
Note
Gonorrhea (blood test)
Gonorrhea (blood test)
Yes
No
Not sure
Date
Note
Hepatitis B
Hepatitis B
Yes
No
Not sure
Date
Note
Polio Vaccination
Polio Vaccination
Yes
No
Not sure
Date
Note
ADDITIONAL INFORMATION
For Children Under the Age of 18
Rotavirus
Rotavirus
Yes
No
Not sure
Date
Note
Hib
Hib
Yes
No
Not sure
Date
Note
Meningococcal
Meningococcal
Yes
No
Not sure
Date
Note
For Seniors
Pneumococcal
Pneumococcal
Yes
No
Not sure
Date
Note
Submit
