fd-1065.pdf

FD-1065

Revised

11-19-2010

FEDERAL BUREAU OF INVESTIGATION

REPORT OF MEDICAL HISTORY

Privacy Act Statement: The collection of this information on this form, which is authorized by 5 U.S.C. § 301 and 5 U.S.C. § 3301, is relevant and necessary to provide appropriate medical care and to determine eligiblity and/or fitness for duty. Completion of this form is voluntary; however, your failure to supply all the information requested on this form may impede or preclude agency action regarding medical care or continued employment.

This infomation is maintained in your medical file in the FBI Centeral records System, Justice/FBI-002, a description of which can be found at http://home.fbinet.fbi/DO/OGC/LTB/PCLU/PrivacyCiv il% 20Liberties% 20Library/Forms/FBI002.aspx. This information may be disclosed in accordance with the routine uses referenced in this notice.

Date of Exam _______________

NOTE: This information is for official and medically-confidential use only and will not be released to unauthorized persons

1. Name of Patient (Last, first, middle) 2. Identification/67# 3. Grade

4. Division/Field Office Address 4a. Examining Facility

4b. City 4c. State 4d. Zip Code

5. Purpose of Examination

5a. Height 5b. Weight 6. Are you (Check One)

G Right Handed G Left Handed

7. STATEMENT OF PATIENT'S PRESENT HEALTH AND MEDICATIONS CURRENTLY USED (Use additional pages if necessary)

8. Present Health 8a. Current Medication 8b. Regular or Interm.

8c. Occupation

9. Allergies (Include insect bites/stings and common foods)

10. PAST/CURRENT MEDICAL HISTORY

Check Each Item Yes No Don't

Know

Check Each Item Yes No Don't

Know

Check Each Item Yes No Don't

Know

Household contact with anyone with tuberculosis

Eye surgery to correct vision Swollen or painful joints

Tuberculosis or positive

TB test

Lack vision in either eye Frequent or severe headaches

Blood in sputum or when coughing

Wear a hearing aid Dizziness or fainting spells

Excessive bleeding after injury or dental work

Wear a brace or back support

Eye trouble

Suicide attempt or plans Stutter or stammer Hearing loss

Sleepwalking Scarlet fever Recurrent ear infections

Check Each Item Yes No Don't

Know

Check Each Item Yes No Don't

Know

Check Each Item Yes No Don't

Know

Wear corrective lenses Rheumatic fever Foot trouble

Severe tooth or gum trouble

Tumor, growth cyst, cancer Nerve Injury

Sinusitis Hernia Paralysis (including infantile)

Hay fever or allergic rhinitis

Hemorrhoids or rectal disease

Epilepsy or seizure

Head injury Frequent or painful urination Car, train, sea or air sickness

Asthma Bed wetting since age 12 Frequent trouble sleeping

Shortness of breath Kidney stone or blood in urine

Depression or excessive worry

Pain or pressure in chest Sugar or albumin in urine Loss of memory or amnesia

Chronic cough Sexually transmitted diseases

Nervous trouble of any sort

Palpitation or pounding heart

Recent gain or loss of weight Periods of unconsciousness

Heart trouble Eating disorder (anorexia bulimia, etc.)

Parent/sibling with diabetes, cancer, stroke or heart disease

High or low blood pressure

Arthritis, Rheumatism, or

Bursitis

X-ray or other radiation therapy

Cramps in your legs Thyroid trouble or goiter Chemotheraphy

Frequent indigestion Sensitivity to chemicals, dust, sunlight

Asbestos or toxic chemical exposure

Stomach, liver or intestinal trouble

Inability to perform certain motions

Plate, pins or rod in any bone

Gall bladder trouble or gallstones

Bone, joint or other deformity

Easy fatigability

Jaundice or hepatitis Loss of finger or toe Been told to cut down or criticized for alcohol use

Broken bones Painful or "trick" shoulder or elbow

Diabetes

Adverse reaction to medication

Recurrent back pain or any back injury

Used tobacco

Skin diseases "Trick" or locked knee

Inability to assume certain positions

Chronic or frequent colds

11. FEMALE ONLY

Check Each Item Yes No Don't

Know

Date of Last

Menstrual Period

Date of Last

Pap Smear

Date of Last

Mammogram

Treated for a female disorder

Change in menstrual pattern

Check Each Item, If "Yes" Explain in Blank Space To Right. List explanation By Item Number.

Item Yes No

12. Have you been treated for a mental condition? If yes, specify when, where, and give details.)

13. Have you been denied life insurance? If yes, state reason and give details.)

14. Have you had, or have been advised to have, any operation? (If yes, describe.)

15. Have you been a patient in any type of hospital? (If yes, specify when, where, why, and name of doctor and complete address of hospital.)

16. Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the year, for other than minor illnesses?

17. Do you have a past or current medical history of any other condition not mentioned on this form?

18. Have you ever received, is there pending, or have you ever applied for pension or compensation for existing disability? (If yes, specify what kind, granted by whom, and what amount, when, why.)

19. Immunization

I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the doctors, hospitals, or clinics mentioned above to furnish the Government a complete transcript of my medical record for purpose of processing my application for this employment or service. I understand that falsification of information on Government forms is punishable by fine and/or imprisonment.

20. Typed or Printed Name of Examinee 20a. Signature 20b. Date

NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL OFFICER ONLY"

21. PHYSICIAN'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician shall comment on all positive answers in Item 7 through 11. Physicians may develop by interview any additional medical history deemed important, and record any significant findings here.)

22. Typed or Printed Name of Physician or Examiner 22a. Signature 22b. Date