Immigration Questionnaires
This form collect specific personal and medical information specifically for immigration physical examination. Please provide as much as information as required.
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First Name: *
Middle Name: *
Last Name: *
Date of Birth (MM/DD/YYYY): *
Sex: *
Country of Birth: *
City/Town/Village of Birth: *
Alien Registration Number (A-Number):
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USCIS Online Account Number (if any):
Form of Identification:
Document Identification Number:
(Unique number on your ID or passport)
 *
1. Have you been treated or hospitalized for psychiatric or mental illness?
(Ha sido tratado u hospitalizado por una enfermedad psiquiátrica o mental?)
 *
2. Have you been treated or hospitalized for alcohol abuse?
(Ha sido tratado u hospitalizado por abuso de alcohol?)
 *
3. Have you been treated or hospitalized for drug abuse?
(Ha sido tratado u hospitalizado por abuso de drogas?)
 *
4. Have you had any history of violent behavior? 
(Ha tenido antecedentes de comportamiento
violento?) *
5. Have you had harmful behavior includes attempted suicide or self-harm (no matter how minor in nature)?
Ha tenido un comportamiento dañino que incluye intento de suicidio o autolesión (sin importar cuán menores sean)?
 *
6. Do you or anyone in your immigrating family have any form of disabilities?
(Tiene usted o alguien de su familia inmigrante alguna forma de discapacidad?)
 *
7. Have you had syphilis or positive VDRL test?
(Ha tenido sífilis o una prueba VDRL positiva?)
 *
8. Have you ever test positive for tuberculosis (TB)?
Alguna vez ha dado positivo en la prueba de tuberculosis (TB)?
 *
9. Have you ever exposed to TB in your household or family?
(Alguna vez ha estado expuesto a la tuberculosis en su hogar o familia?)
 *
10. Have you ever had an abnormal X-ray? 
(Alguna vez ha tenido una radiografía anormal?)
 *
11. Prior history or treatment for syphilis?
(Historia previa o tratamiento para la sífilis?)
 *
12. Sexual partner with syphilis?
(Compañero sexual con sífilis?)
 *
13. Any history of painless sores on the genitals, anus, or mouth or rash on the body especially on the palms of the hands or soles of the feet?
(Tiene antecedentes de llagas indoloras en los genitales, el ano o la boca o sarpullido en el cuerpo, especialmente en las palmas de las manos o las plantas de los pies?)
 *
14. For MEN: Dysuria with penile discharge in men? (Disuria con secreción peneana en hombres?)

For WOMEN: Vaginal mucopurulent discharge, pelvic pain, or dyspareunia in women? (Secreción
mucopurulenta vaginal, dolor pélvico o dispareunia en mujeres?)
*
15. History of chronic bacterial disease that primarily affects the skin and peripheral nerves? 
(Historia de enfermedad bacteriana crónica que afecta principalmente la piel y los nervios periféricos?) 
*
16. Physical exam as: any anesthetic skin patches, with or without visible lesions, localized skin lesions with raised, flat, nodular, light or pigmented?
(Examen físico como: cualquier parche cutáneo anestésico, con o sin lesiones visibles, lesiones cutáneas localizadas con relieve, plano, nodular, claro o pigmentado?)
*
17. Sensory loss in lesion or on fingers or toes (use monofilament or cotton wisp to evaluate)?
Pérdida sensorial en la lesión o en los dedos de las manos o de los pies (use monofilamento o mechón de algodón para evaluar)? 
*
18. Painless wounds or burns?
(Heridas o quemaduras indoloras?)
*
19. Thickened peripheral nerves (ulnar, radial, peroneal)?
Nervios periféricos engrosados (cubital,
radial, peroneo)? 
*
20. Loss of eyebrows?
(Pérdida de cejas?)  
*
21. Thickening of earlobes?
(Engrosamiento de los lóbulos de las orejas?)
*
22. Atrophied hand muscles?
(Músculos de la mano atrofiados?) 
*
23. Lagophthalmos (inability to fully close the upper eyelid)?
Lagoftalmos (incapacidad para cerrar
completamente el párpado superior)?
*
24. Perforated nasal septum?
(Tabique nasal perforado?) 
*
25. Acid-fact bacilli in lesion.
(Bacilos acidorresistentes en lesión)
*
26. History of Chicken Pox?
(Historia de la varicela?) 
*
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