Children aged 11 and younger who will accompany a parent to an overseas post need a State Department medical clearance, and DS-1622 is the history and physical used to decide it. The parent or sponsor completes the history pages, and the child's pediatrician or other provider performs the exam, TB screening and assessment that the Bureau of Medical Services (MED) reviews.
The parent or employee sponsor completes pages 1 to 3 (demographics, medical and mental health history, medications, hospitalizations and specialty care) and signs page 3. The medical examiner completes pages 4 and 5: comments on positive history, clinical evaluation, physical exam, TB screening, assessment, recommendations and signature.
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Medical History and Examination for Children Age 11 and Younger
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The instructions say the medical examiner must comment on positive history from page 2, describe abnormal physical findings on page 4, give follow-up recommendations on page 5 and sign on page 5. The exam section lists 14 body systems marked normal, abnormal or not evaluated, with each abnormality described.
DS-1843, Medical History and Examination for Individuals Age 12 and Older, which adds required labs and, from age 50, an ECG. DS-1622 covers children 11 and younger. Both carry OMB number 1405-0068 and the same submission rule: electronic only, never by mail or courier.