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history taking and physical examination

Oct 26, 2023

Immigration and Health

Documenting Health: History Taking and Physical Examination in Immigration

Are you planning to immigrate to the USA? Thinking of becoming a permanent resident of the USA (green card holder)? If your answer is yes, you must clear a mandatory immigration medical examination. Also referred to as the green card medical examination, it includes history taking and physical examination of the individual.

Medical immigration documentation and disclosure are crucial for individuals and host nations alike. The history taking and physical examination ensure that the individual is physically and mentally fit to adjust his/her immigration status. This keeps the public safe and makes it possible for potential immigrants to be accepted without any issues.

Understanding the Immigration Process

Initially, you have to file a petition for commencing the immigration process. The U.S. Citizenship and Immigration Services (USCIS) reviews and approves the petition, after which the immigration visa application starts. Along with biometrics, you will have to appear for the immigration medical examination. After a proper evaluation of your physical and mental health, your immigration processing will proceed.

The Role of History Taking in Immigration

In the preliminary health screening appointment, the medical professional will review your overseas medical documents and obtain a detailed history, which includes documentation of general past medical history, allergies, family history, medications, vaccination history, social history, environmental exposure history, travel history, mental health history, substance use history, and sexual history.

The Importance of Physical Examination in Immigration

After history taking is completed, it is time for a comprehensive physical examination. Applicants do not have to undress for the exam. Items that are checked in the physical examination include:

  • Examination of exposed skin
  • Head, eyes, ears, nose, and throat (HEENT)
  • Neck
  • Heart & Lungs
  • Abdomen
  • Neurological exam (reflexes etc)
  • Extremities

You might also have to take specific medical tests like:

  1. Tuberculosis (TB) blood test (age 2 years and older)
  2. Urine test for gonorrhea (age 18 – 24)
  3. Blood test for syphilis (age 18 – 44)
  4. Chest X-ray (only if TB is suspected)

After the health examination, the Civil Surgeon evaluates your general health condition and identifies any problems. If there are no issues, you get a medical clearance report at that time.

In case of any problem, you will be asked to take the necessary treatment. Special circumstances excepted, you must be declared fit physically and mentally to be able to proceed with your immigration processing.

The Significance of Accurate Documentation

Once history taking and physical examination are completed, the panel physicians and/or civil surgeons document all the details accurately in the necessary forms and related worksheets. The forms should contain the signatures of the civil surgeon, the applicant, and any other healthcare providers who have evaluated you. The form may also include the signatures of officials from the Health Department.

False or misleading information regarding the physical or mental health condition might bring negative consequences for you and the doctors involved in your case.

Protecting Public Health: Host Nation’s Perspective

History taking and physical examination contribute to public health significantly. Suppose you have a contagious disease, and you manage to clear the medical test unscrupulously, and you also tend to get immigration clearance to become a resident of the USA. You will become a threat to public health and safety, as there is a chance that you might transmit the disease to someone else in the new country.

As a result, the civil surgeon must ensure that medical clearance is provided only to individuals that meet the minimum health requirements, so that there are no threats to public safety through the spread of diseases.

Tips for a Successful Immigration Medical Evaluation

Start preparing immediately after getting the appointment for history taking and physical examination. Here are the documents which you should bring:

  • Vaccination and immunization records
  • Copies of any previous chest X-rays
  • Any tuberculosis (TB) testing and treatment records
  • Any syphilis testing, treatment, & monitoring records
  • Photo ID issued by the government like state ID, passport, travel permit, driver’s license, etc.

Present these documents immediately when needed. Talk openly with your civil surgeon if you feel nervous, have any questions or confusion, or feel uncomfortable.

Ensuring Privacy and Confidentiality

During the immigration medical examination process, maintaining patient-doctor confidentiality and privacy is of utmost importance. The doctors involved in the examination are not at liberty to discuss the evaluation of the tests with anyone other than you or someone whom you designate. However, by law, TB, syphilis, and gonorrhea infections must be reported to the local health department.

Clear Immigration Medical Exam with Steven Wittenberg Gordon, MD

No immigration formality is complete without history taking and physical examination. It is essential to provide accurate and proper documentation along with the medical evaluation report.

Steven Wittenberg Gordon, MD. offers immigration medical exams for candidates. With more than 20 years of experience as a United States civil surgeon, Dr. Gordon excels as an immigration doctor. Contact us today or call us directly at 913-787-5805 for more information.

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