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The form captures examinee information such as name, chosen name, date and place of birth, sex, status, agency, exam purpose, employment category, and assignment arrival data. It also lists medical history questions requiring yes answers to include explanations with dates of occurrence. It includes a legal notice under the Genetic Information Nondiscrimination Act (GINA) instructing providers not to request or provide genetic information when responding.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/demographic-information-medical-history-examination-form/194449/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/demographic-information-medical-history-examination-form/194449.png","ImageObject",442,249,{"name":88,"@type":89},"Eliana","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-08","2026-09-03",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information does the form collect in Section I (Demographic Information)?","Question",{"text":108,"@type":109},"It collects examinee identity and background details such as name (including chosen name), date and place of birth, sex, status, agency/employer category, exam purpose, employment status, contact information, and assignment/post and arrival date.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What must be provided when answering “Yes” to medical history questions?",{"text":113,"@type":109},"All “Yes” answers require a written explanation with the date of occurrence entered in the designated response box (IIA).",{"name":115,"@type":106,"acceptedAnswer":116},"What does the GINA notice require the medical history reviewer or provider to do?",{"text":117,"@type":109},"It states that genetic information must not be requested or provided when responding to the medical information request, as genetic information is restricted under the Genetic Information Nondiscrimination Act of 2008.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},194449,1790017855,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":135,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":47,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":73},4398048949847,"https://ap-avatar.wpscdn.com/avatar/400002536579ef2da7f?_k=1778318612642679267","| I. DEMOGRAPHIC INFORMATION\u003Cbr>TO BE FILLED OUT BY EXAMINEE (OR PARENT) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | DATE OF EXAM (mm-dd-yyyy) |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| 1a. Name of Examinee (Last, First, MI) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 1b. Chosen Name of Examinee |  |  |  |  |  |  |  |  |  | 2. If Eligible Family Member, Name of Employee/Applicant |  |  |  |  |  |  |  |  |\n| 3. Date of Birth of Examinee (mm-dd-yyyy) |  |  |  |  |  |  |  |  |  | 4. Place of Birth of Examinee\u003Cbr>City   State   Country   |  |  |  |  |  |  |  |  |\n| 5. Sex |  |  | Male | 6. Status |  |  |  | Employee | |  | Dependent Child |  |  | |  | Spouse |  |  |\n|  Female |  |  |  |  Applicant |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 7. Agency of Employee/Applicant/Sponsor\u003Cbr> STATE  FCS  FAS  U.S. Agency for Global Media  DoD Civilian  DoD Contractor\u003Cbr> Other Government Agency    Contracting Company   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 8. Purpose of Exam\u003Cbr> Pre-Employment  In-Service  EFM  Re-Employed Annuitant (REA-WAE) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 9. Employment Status of Employee/Applicant/Sponsor |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | Civil Service\u003Cbr>Foreign Service\u003Cbr>Personal Service Contractor (PSC) |  |  |  |  | 3rd Party Contractor\u003Cbr>Limited Non-Career Appointment (LNA)\u003Cbr>Fellow |  |  |  |  |  |  | Locally Employed Staff (LES)\u003Cbr>Consular Affairs-EFM (CA-EFM)\u003Cbr>Other:   |  |  |  |  |  |\n| 10. E-mail Address of examinee or parent of child \u003C 18 y/o (Where you can be reached to discuss examinee medical information)\u003Cbr>Primary:  \u003Cbr>Alternate:   |  |  |  |  |  |  |  |  |  | 11. Assignment Type\u003Cbr> Temporary Duty (Regional hub or CONUS based)\u003Cbr> Permanent Change of Station/Post of Assignment |  |  |  |  |  |  |  |  |\n| 12. Telephone Number of examinee or parent of child \u003C 18 y/o (Where you can be reached to discuss examinee medical information)\u003Cbr>Primary:  \u003Cbr>Alternate:   |  |  |  |  |  |  |  |  |  | 13. Post of Assignment and Estimated Date of Arrival (if applicable) Proposed Post:  \u003Cbr>EDA (mm-dd-yyyy):  \u003Cbr>*If the above is an ESCAPE post, please complete a DS-6570 form. |  |  |  |  |  |  |  |  |\n| To the individual and/or health care provider completing the medical history review /exam: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law we are asking that you NOT provide any genetic information when responding to this request for medical information. 'Genetic Information' as defined by GINA, includes an individual's family medical history, the results of an individual's or family members' genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n\n\n| Name of Examinee |  |  |  |  |  |  | DOB |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| II. MEDICAL HISTORY |  |  |  |  |  |  |  |\n| ANSWER THE FOLLOWING QUESTIONS: ALL YES ANSWERS MUST HAVE A WRITTEN EXPLANATION WITH DATE OF OCCURENCE IN BOX IIA. YOU MAY BE FULLY RESPONSIBLE FOR MEDICAL EXPENSES/NOT ELIGIBLE FOR MEDEVAC FOR UNDISCLOSED MEDICAL INFORMATION. |  |  |  |  |  |  |  |\n| Does examinee have a history of: |  | Yes No\u003Cbr>  26. Blood transfusion?\u003Cbr>  27. Malaria, tropical or other infectious disease?\u003Cbr>  28. Any skin","cbCaipNoA4t4V8VH","https://ap.wps.com/l/cbCaipNoA4t4V8VH","pdf",485032,8,"English","# I. DEMOGRAPHIC INFORMATION\n## Medical information review and GINA notice\n# II. MEDICAL HISTORY\n## Medical history questions (yes/no)","[{\"question\":\"What information does the form collect in Section I (Demographic Information)?\",\"answer\":\"It collects examinee identity and background details such as name (including chosen name), date and place of birth, sex, status, agency/employer category, exam purpose, employment status, contact information, and assignment/post and arrival date.\"},{\"question\":\"What must be provided when answering “Yes” to medical history questions?\",\"answer\":\"All “Yes” answers require a written explanation with the date of occurrence entered in the designated response box (IIA).\"},{\"question\":\"What does the GINA notice require the medical history reviewer or provider to do?\",\"answer\":\"It states that genetic information must not be requested or provided when responding to the medical information request, as genetic information is restricted under the Genetic Information Nondiscrimination Act of 2008.\"}]","Demographic Information - Medical History Examination Form | PDF",1788439223]