US VISA Application Form test

US VISA Application Form test2019-06-26T03:00:15+00:00





1.Past Medical History


Illness or injury requiring hospitalization (including psychiatric)


Hypertension
Congestive heart failure or coronary artery disease
Arrhythmia
Rheumatic heart disease
Congenital heart disease


Tobacco use




Diagnosed(yyyy/mm)

Treated(yyyy/mm)

Fever
Cough
Night sweats
Weight loss


Major impairment in learning, intelligence, self-care, memory, or communication
Major mental disorder(including bipolar disorder, major depression, mental retardation, post-traumatic stress disorder,schizoaffective disorder, schizophrenia)

Use of drugs other than those required for medical reasons Addiction(dependence) or abuse of specific substances or drugs on the CSA
Other substance related disorders(including alcohol abuse or dependence)
Ever caused serious injury to others, caused major property damage or had trouble with the law because of medical condition,mental disorder, or influence of alcohol or drugs
Ever had thoughts of harming yourself
Ever acted on those thoughts
Ever had thoughts of harming others
Ever acted on those thoughts
Psychological/ Psychiatric Disorder (including major depression, bipolar disorder, or schizophrenia)
Substance use or substance induced disorders of substances on the Controlled Substances Act (CSA)
Substance use or substance induced disorders of substances not on the CSA (including alcohol)


History of stroke
Seizure disorder


Pregnancy,current
Estimated delivery date
Pregnancy
birth dates






Gonorrhea

Granuloma inguinale

Syphilis


Diabetes mellitus
Thyroid disease


Anemia
Sickle Cell Disease
Thalassemia


An abnormal or reactive HIV blood test
Diagnosed (yyyy/mm)
Kidney or Bladder disease
specify:
Chronic renal disease
Chronic liver disease(including hepatitis B or C)
Hansen's Disease
Diagnosed(yyyy/mm)
Treated(yyyy/mm)
Other medical conditions requiring treatment
specify:
Disabilities(including loss of arms or legs)
specify: