Immigration Medical Exams

1. Last Name (All as they appear on your PASSPORT):
2. First and middle name(s):
3.Date of birth (MM/DD/YYYY):
4. Home Address (not PO BOX) to be use on your USCIS medical report:
5. Apartment or Unit number (if any):
6. Country of birth:
7.  City or town of birth (as it appears on your Passport):
8. Do you have an employment authorization card or have you received any USCIS letters? Yes or No?
9.  If you replied “YES” on question #8, please write down your Alien number (9 digits):
10. Passport number:
11.  Passport expiry date (write the month in words)
12. Country of passport:
13.  E-mail:
14.  If you have Health insurance, what is the name of your insurance carrier?
15.  *Do you speak and understand English fluently? Would you need an interpreter if a USCIS officer were to interview you face to face?
16. What is your phone number?
17.  Have you ever been sick with the “chicken pox”/Varicella?
18. Have you ever been sick with COVID?
19. Have you been vaccinated against COVID? If so, when? 

*if you do not speak English fluently, you will be required to bring an interpreter. USCIS strictly requires that an interpreter SIGNS the I-693 Form on the day of your appointment.