INSTRUCTIONS FOR MEDICAL EXAMINATIONS IV/DV/K-1 __________

Dear visa applicant,

Please read the instructions carefully. All intending immigrants, regardless of age, are required to
undergo a medical examination by one of the panel physicians, listed below:
Dr. Dritan & Dr. Elsa Muzha
Dr. Dritan Cela
U.S. Consular Office Panel Physician, Tirana
U.S. Consular Office Panel Physician, Tirana
Boulevard Gjergj Fishta, Nd. 6, H. 9
Rr. Teodor Keko, Pall. Edglis, Kt. 2
Njesia Bashkiake 10, Kodi postar 1001
Ish Astiri, Unaza e Re
(8-floor tower, green color)
Tirana, Albania
Tirana, Albania
Cell: +355-(0)66-401-9459
Cell: +355-(0)68-202-4950
E-mail: [email protected]
[email protected]

Dr. Dritan &

Elsa Muzha

Map of Dr. Dritan & Dr. Elsa Muzha's Office (crtl+click on the map to open the location.)

Map of Dr. Dritan Cela's office (crtl+click on the map to open the location.)

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Consular Section, U.S. Embassy, Tirana

Last revised on 3/3/2015

Please fill out this application form with your name, surname, date of birth, and age, prior to your medical
examination appearance:
Name

Surname

Date of Birth and Age

If you come to the Panel Physicians Office with incomplete or incorrect identification cards and/or vaccination
cards, both your medical examination and your visa interview date may be delayed. To avoid unnecessary
delays with the processing of your case, we advise you to come fully prepared to your medical examination
appointment with all the required documents.
For your convenience, and in order to avoid any delays, your medical examination is scheduled in two phases:
A. FIRST APPOINTMENT - VERIFICATION OF DOCUMENTS. Only the principal applicant, not the entire family,
must appear exactly three weeks prior to their visa interview date between 09:00-11:30 a.m. to submit the
documents listed below. (For example: if the interview date in the envelope that you have received from the
National Visa Center, Consular Section, or Kentucky Consular Center falls on a Tuesday, then your first
appointment will fall on the Tuesday three weeks prior to the interview date, OR, as scheduled by the Panel
Physician's Office staff.) In the rare cases where the appointment package is received less than three weeks
prior to the visa interview date, applicants should contact the eligible physicians during their business hours
(9:00 a.m. to 16:00 p.m., Monday through Friday) to schedule an appointment as soon as possible, or they may
come to one of the aforementioned addresses between 09:00-11:30 a.m. along with all the required
documentation.
During the first appointment, NO medical examination will take place. The family members will show up for
their medical examination in the second appointment (see below.) The Panel Physician staff will check your
documents listed below, and will provide you with instructions regarding the examinations; recommendations,
vaccination cards, or any missing vaccination/s for you and your family members, and will provide you with the
date and time for the second appointment for you and your family members (if applicable.) This allows
applicants to have time to complete any missing documents they may have.
The principal applicant must submit the following documents for each visa applicant in both appointments (a)
verification of documents and b) medical examination) as follows (Mark with X all the documents that you will
submit to the Panel Physician Office):

This instruction package:

Your Passport/s and copy of passport/s - adults and children (the originals and a legible photocopy of
every passport that will be submitted to our office);

Your personal vaccination card/s and copy of it (the original and a legible photocopy for each card to be
submitted to our office);

Your appointment letter;

Instructions for Medical Examinations, filled out with the names and the ages of all the applicants that
are to be examined (see page #2);

Fill out the personal medical declaration on pages #5 & 6 for each visa applicant prior to your medical
appointment, containing your complete medical history, and with a personal photograph attached to it.
This declaration will be submitted to our office during the first phase of your medical appointment;

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Consular Section, U.S. Embassy, Tirana

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Fill out the information on page #7 for each visa applicant prior to your medical appointment.
Five (5) 3x4 cm photographs for each person, taken in full-face view directly facing the camera, (taken
within the last six months, and one of them must be attached to the personal medical declaration);

Medical reports, blood tests, etc.;

All the aforementioned documents must be in Albanian (both the originals and the photocopies) and they do
not need to be translated or notarized.
B. SECOND APPOINTMENT: MEDICAL EXAMINATION. All visa applicants, regardless of age, will show up for
their medical examination one week prior to their visa interview date*, OR, as scheduled by the Panel
Physicians Office staff, *. You will submit to the Panel Physician all the required documents listed above, as
well as any additional documents that may be requested by the Panel Physicians Office during the first
appointment for you and your family members (if applicable). Please note that this is a very lengthy process
and both you and your family members will need to spend the entire day undergoing various medical
examinations at Glob Clinic. Once the results are available, you will need to sign the medical forms in front of
the Panel Physician. The results will be provided to you in a sealed envelope, which you must NOT open.
*If one of the above days coincides with a public holiday, you will need to call the Panel Physicians Clinic,
during their business hours (09:00 a.m. to 16:00 p.m., Monday through Friday) in order to reschedule your
medical appointment.
The fee for adults (15 years and above) is $145.00 (includes physical examination, chest x-rays, blood tests, and
Syphilis). The fee for children under 15 years of age is $100.00.
In some cases, in order to assess the health status of the applicant, further examinations may be required. If
this applies to your case, you must follow the Panel Physician's instructions regarding any additional tests. The
applicant is responsible for any additional costs for any such examinations, except for Tuberculosis treatment.
In order to avoid extra examinations, you should include all medical reports for any medical issues or illnesses
you may have, including any previous blood tests. Pregnant women should have a gynecological ultrasound as
well as a complete medical report from their gynecologist where the pregnancy gestation age must be included
as well.
Important Notice: In accordance with the Center for Disease Control and Prevention (CDC) instructions, you
may be required to undergo additional testing for Tuberculosis (TB), which may take an additional time of 8-10
weeks for the results to become available. The Panel Physicians Office will notify the U.S. Consular Section
regarding any applicants referred for further TB culture testing, so that they dont experience any delays on
the date of their visa interview. If the applicants results are TB positive, he or she will need to undergo a
compulsory TB treatment by the Panel Physicians staff.
The results of your medical examination may be released to the applicant only, or directly to the U.S. Consular
Section. Only employees of the Consular Section may open the sealed envelope. You may not open the
envelope. You should not send the X-Ray CD to the U.S. Embassy, unless you are an asylee. You will be provided
with a copy of your vaccination documentation worksheet, which you may need in order to be able to register
your child into a U.S. school, etc.
By signing the DS-2054 application, you personally authorize and agree to undergo the medical examination.
Note from the U.S. Consular Section: The validity of your visa will be limited to the validity of your medical
report. Medical reports classified as "Class B (TB)" are valid for 3 months from the date on which the doctor
signed the report. All other medical reports classified as "No apparent disease or defect" are valid for 6 months
from the date on which the doctor signed the report. If your case is subject to further administrative processing,
or if the processing of your file is delayed due to missing documents, the medical report may expire before your
visa is issued. In that case, you will be required to renew the examination and submit an updated medical report
to the Consular Section before you receive your visa. In such cases, you will be required to pay a new medical
examination fee. The fee for adults (15 years and above) is $145.00, and the fee for children under 15 years of
age is $100.00.
The payment for the medical examination will not be refunded, regardless of the result of your visa
application.

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Consular Section, U.S. Embassy, Tirana

Last revised on 3/3/2015

Note: You must appear for your medical appointment only on the date and time of your appointment. Do not
appear to the panel physicians office on dates or times other than those specifically scheduled for you, unless
you are instructed to do so by the Consular Section itself.
The medical staff is not responsible for any delays pertaining to the processing of your visa case by the U.S.
Consular Section.
INSTRUCTION FOR VACCINATIONS
On the day of their first medical appointment, the principal applicant must provide all personal vaccination
cards for each family member who is applying for an immigrant visa, containing records of all vaccinations
received throughout their entire life. Only the vaccination cards that were issued by the appropriate health
centers containing the applicants name, fathers name, surname, birthday, exact vaccination and
revaccinations date records are considered valid and acceptable vaccination cards. . A personal vaccination card
must also have the stamp of the health center, a clearly legible name of the physician together with his or her
signature.
If you do not submit the vaccination card during the medical examination, you will be considered unvaccinated.
Any vaccine records for which the receipt dates are not written in or are written in only partially will not be
taken into consideration.
The vaccinations available in Albania are as follows:
1) D.T.P. (Diphtheria/Tetanus/Pertussis) .. 4 doses
2) D.T. (Diphtheria/Tetanus) revaccination. 2 doses
3) Polio. (Poliomyelitis) 3 doses + extra dose
4) Measles ... 1 dose
5) Measles - Rubella . 1 doses
6) Measles Rubella Parotid . 2 doses
7) H.V.B. (Hepatitis B) . 3 doses
8) HiB ........ 3 doses
9) Pneumococcus . 3 doses
10) Rotavirus
11) Meningococcal
12) Varicella
Some of these vaccines are not administered for all ages.
If any of the following applies to your case: a) you are not vaccinated; b) you did not take the last vaccines
recently arrived; c) you do not have any document that proves your vaccination; d) you have partially recorded
vaccination, we suggest that you receive the first dose of any vaccine that has never been administered to you
or which is not properly documented prior to showing up for your medical examination. If you have received
some of the vaccination doses or are not properly vaccinated, you must receive the next revaccination dose.
Any of the vaccines that are administered to you must be recorded on the vaccination card by the appropriate
health center.
Your personal vaccination card is the only document that certifies your vaccination. No other documents will
be accepted. Check for the authenticity of the vaccination card. It is an official document and the applicant who
will present it bears full responsibility for its authenticity. Do not allow recording of any vaccinations that you
havent actually received or which are not recorded in the Official Registers. All vaccinations and revaccinations
are administered according to the immunization scheme approved by the Albanian Public Health authorities. If
you received any other vaccines, not listed in the aforementioned list of vaccinations available in Albania, you
will be required to provide any such vaccination records to the Panels Physicians Office as well
Note: applicants who have travelled to any of these countries within the last 12 months: Pakistan, Syria,
Equatorial Guinea, Afghanistan, Ethiopia, Iraq, Israel, Somalia, or Nigeria, must bring proof of vaccination for
Poliomyelitis, and they should inform the Panel Physicians Office of that.

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Consular Section, U.S. Embassy, Tirana

Last revised on 3/3/2015

PERSONAL MEDICAL DECLARATION

Complete this form and attach your photo prior to undergoing medical examination. This form is part of your medical
documentation. Each person must complete and sign the form For those who are under the age of 16, the form may be
filled out by a parent.
Check the YES or NO box according to your health situation.

ph

________________________ ________________ Age: ____ y.o.,

Surname
Name
Gender:
Education completed:

minor

F
elementary

high school

college

Profession: _____________________________________________________________________________________-_
Weight: _________ Kg;

YES

NO

Height: __________ cm

GENERAL

Illness or injury requiring

hospitalization (including
psychiatric)
Any surgical procedure or caesarian
section? Explain:

YES

NO

CARDIOLOGY
Heart Disease
Angina pectoris (infarcts, preinfarcts)
Hypertension (high blood pressure)
Cardiac arrhythmia
Congenital heart disease

YES

NO

PULMONOLOGY

YES

NO

NEUROLOGY & PSYCHIATRY

History of stroke, with any current

impairment
Seizure disorder
Major impairment in learning,
intelligence, self-care, memory or
communication
Major mental disorder (including
major depression, bipolar disorder,
schizophrenia, mental retardation)
Use of drugs other than those
required for medical reasons
Addiction or abuse of specific*
substance (drug). *amphetamines,
cannabis, cocaine, hallucinogens
Opioids, phencyclidines, sedativehypnotics, anxiolytics
Other substance-related disorder
(including alcohol addiction or abuse)

History of tobacco use

Have you ever attempted suicide?

Are you currently smoking

Have you ever caused SERIOUS injury

to others, caused MAJOR property
damage or had trouble with the law
because of medical condition, mental
disorder, or under the influence of
alcohol or drugs

Asthma
Chronic obstructive pulmonary
disease (emphysema)
History of tuberculosis (TB) disease
Have you ever been treated for TB?

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Consular Section, U.S. Embassy, Tirana

Last revised on 3/3/2015

YES

NO

OBSTETRICS & SEXUALLY

TRANSMITTED DISEASE

History of Varicella

Are you pregnant?

Have you ever belonged to a a group

of physicaly disabled

If so, list Estimated Delivery date:

YES NO HANSEN

_____________ (date-month-year)

Hansen's Disease

Do you have any sexually transmitted

disease, (specify):

Paubacillary

________________________________

YES

NO

Treated:

Yes

Multibacillary

No

________________________________

Do you have visible disabilities

(including loss of limbs (Specify):

ENDOCRYNOLOGY & HEMATOLOGY

_________________________________

Diabetes mellitus

_________________________________

Thyroid disease
History of malaria
YES

NO

OTHER
Malignancy (specify)

Do you have other conditions requiring

treatment, specify:
_________________________________
_________________________________
MARITAL STATUS

Chronic renal disease

Single

Married

Chronic hepatitis or other chronic liver

disease

Widowed

Divorced

Did you serve in the military service?

If not, explain why:
--------------------------------------------------Do you have vision

problems (glasess,

etc.)

NOTE:

All health problems must be documented through medical reports, blood

or other medical tests, prescriptions etc.

I, THE UNDERSIGNED DECLARE THAT ALL THE INFORMATION GIVEN BY ME IS TRUE AND
COMPLETE.
_____________________________________________________
NAME
SURNAME
SIGNATURE
Date _________________

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Consular Section, U.S. Embassy, Tirana

Last revised on 3/3/2015

Fill out the information below for each visa applicant, regardless of age
(Make copies for each visa applicant)
Name (Last, First)
Birth Date

Sex

Passport Number

Case Number

Birthplace (City, Country)

Present Country of Residence
Prior Country of Residence
Present Address of Residence
Present City of Residence
Present Postal Code of Residence
Intended US Address
Intended US City, State, and Postal Code
Visa Category

Immigrant

DV Lottery

K- Visa (Fiance)

Adoption

NIV (Non-immigrant)

Visa 92 (Asylee)

Cell Phone Number

E-mail Address
Name of ALL Child(ren) (if applicable to you) and their Date of Birth (mm-dd-yyyy) :
Name, Last Name

Date of Birth

1.
2.
3.
4.
5.
6.

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Consular Section, U.S. Embassy, Tirana

Last revised on 3/3/2015

UDHZIME MBI VIZITN MJEKSORE IV/DV/K1

I nderuar Aplikant i vizs,
Lutemi lexoni udhzimet me kujdes. T gjith aplikantt e vizs emigruese, pavarsisht moshs, duhet ti
nnshtrohen nj vizite mjeksore tek nj nga mjekt e mposhtm:
Adresa 1:
Dr. Dritan Muzha & Dr. Elsa Muzha
Bulevardi Gjergj Fishta, Kulla 6, Hyrja 9
(Kulla 8 katshe, jeshile me stem)
Tiran, Shqipri
Celular: (+355)-(0)68-202-4950
[email protected]

Adresa 2:
Dr. Dritan Cela
Rr. Teodor Keko, Pall. Edglis, Kt. 2
Ish Astiri, Unaza e Re
Tiran, Shqipri
Celular: (+355) -(0) 66-401-9459
[email protected]

Dr. Dritan &

Elsa Muzha

Adresa e Dr. Dritan dhe Elsa Muzha (crtl+kliko pr t hapur hartn e zyrs)

Adresa e Dr. Dritan Cela (crtl+kliko pr t hapur hartn e zyrs)

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Consular Section, U.S. Embassy, Tirana

Last revised on 3/3/2015

Plotsoni formularin me emrin, mbiemrin, datlindjen dhe moshn e secilit aplikant prpara se t paraqiteni pr
vizitn mjeksore:
Emri

Mbiemri

Datlindja dhe Mosha

Nse ju paraqiteni tek mjeku me me dokumente identifikimi dhe kartela vaksinimi t paplotsuara dhe/ose t
parregullta, si vizita mjeksore ashtu edhe data juaj e intervists mund t shtyhen n koh. Pr t shmangur vonesa
t panevojshme, ne ju kshillojm q t paraqiteni t prgatitur plotsisht me dokumentacion t plot n ditn tuaj
t takimit pr vizitn mjeksore t cilat krkojn koh pr t'u plotsuar.
Pr lehtsin tuaj dhe pr t shmangur ndonj vones, paraqitja juaj pr vizitn mjeksore sht programuar n dy
faza:
A. Takimi i Par: VERIFIKIMI I DOKUMENTACIONIT. Vetm aplikanti kryesor, jo e gjith familja, do t paraqitet fiks
tre jav para dats s intervists, nga ora 09:00 11:30 pr t dorzuar dokumentet e renditura m posht (festat
zyrtare, e shtuna dhe e diela jan pushim). (Pr shembull: Nse data e intervists n zarfet q ju kan ardhur nga
Qendra Kombtare e Vizave, Seksioni Konsullor, apo Qendra e Lotarive bie ditn e mart, ather dita e paraqitjes
pr verifikimin e dokumentave do t jet dita e mart e tre javve prpara dats s intervists.) N rastet e rralla kur
letra e takimit ju ka mbrritur m pak se 3 jav nga data e intervists, ju duhet t kontaktoni gjat orarit zyrtar
(09:00 16:00, nga e hna n t premte) stafin mjeksor pr t caktuar takimin sa m par, ose paraqituni
personalisht gjat orarit 09:00 11:30 pran njrs prej adresave t msiprme s bashku me dokumentet e
shnuara m posht.
N takimin e par, NUK do t kryhet vizit mjeksore. Stafi i mjekve t autorizuar do t kontrolloj dokumentet e
renditura m posht; do ju jap udhzime n lidhje me analizat, rekomandimet, kartelate vaksinimit, plotsime q
duhen n kartelat e vaksinimit, si dhe do t prcaktohet data dhe ora e sakt e paraqitjes pr vizitn mjeksore me
t gjith familjen. Antart e familjes suaj do t paraqiten pr vizit e tyre mjeksore n takimin e dyt (shiko m
posht).N kt mnyr do t ket koh pr plotsimet e duhura.
Dokumentat q DUHET t keni me vete kur t paraqiteni n t dyja fazat (Verifikimi dhe Vizita mjeksore) jan
(vendosni nj kryq tek secili dokument q po dorzoni tek stafi mjeksor):

Pasaporta(t) dhe kopje t pasaportave - t rritur dhe fmij (Origjinalin/et dhe nga nj fotokopje t qart t
tyre, e cila do t dorzohet tek mjeku).
Karteln/at personale t vaksinimit dhe kopje t saj (Origjinalin/et dhe nga nj fotokopje t qart t tyre, e
cila do t dorzohet tek mjeku).
Dokumentin q ju njofton datn e intervists (T dyja flett).
Udhzuesin e vizits mjeksore, t plotsuar me emrat, datlindjet dhe moshn e personave q do t
vizitohen (shikoni faqen nr. 9 t ktij udhzuesi).
Deklaratn mjeksore personale pr secilin person, t plotsuar saktsisht dhe t pajisuar me fotografi
(shikoni faqet nr. 12 & 13).
Plotsoni informacionin n faqen 14 pr secilin aplikant t vizs, pavarsisht moshs.
Pr do person pes (5) fotografi 3x4 cm ballore t nxjerra 6 muajt e fundit, njra nga t cilat do t ngjitet n
deklaratn mjeksore personale.
Raportet shndetsore, epikriza, analiza, libreza shndetsore, etj.

I gjith dokumentacioni shqip (origjinalet dhe fotokopjet) nuk kan nevoj pr prkthim ose noterizim.

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Consular Section, U.S. Embassy, Tirana

Last revised on 3/3/2015

B. Takimi i Dyt: VIZITA MJEKSORE. T gjith aplikantt e vizs, pavarsisht moshs, do t paraqiten fiks nj jav
prpara dats s tyre t intervists*, OSE sipas dats s caktuar nga stafi mjeksor*. Ju do t dorzoni tek stafi
mjeksor t gjith dokumentacionin e renditur m lart dhe dokumentacion shtes t krkuar n takimin e par, pr
ju dhe pr familjen tuaj (nse aplikohet). Vini re q vizita mjeksore do t zgjas shum dhe ju e familja juaj do t
duhet t kaloni gjith ditn me vizita mjeksore t ndryshme tek Klinika Glob. Pasi t ken dal rezultatet, ju do t
firmosni formulart prpara mjekut t autorizuar. Rezultatet e vizits do ju jepen n nj zarf t vulosur, t cilin ju
NUK duhet ta hapni.
* Nse njra nga ditt e msiprme rastis t jet dit pushimi apo fest komtare, ju duhet t telefononi stafin
mjeksor gjat orarit zyrtar (09:00 16:00 nga e hna n t premte) pr t ricaktuar takimin tuaj.
Tarifa pr t rriturit (mosha 15 vje e lart) sht 145 Dollar (n kt pages prfshihet ekzaminimi fizik, radiografia
e gjoksit dhe analiza pr sifiliz). Pagesa pr fmijt nn moshn 15 vje sht 100 Dollar.
Gjat kontrollit mjeksor mund t lind nevoja pr ekzaminime shtes pr t prcaktuar gjendjen shndetsore.
Nse nj gj e till aplikohet pr rastin tuaj, ju duhet t ndiqni udhzimet e stafit mjeksor rreth analizave shtes.
Tarifat pr ekzaminimet shtes jan n ngarkim t aplikantit, prve trajtimit t Tuberkulozit. Nse smundja ose
problemi shndetsor njihet paraprakisht, pr sqarim nevojiten raportet shndetsore, epikriza, libreza
shndetsore, analiza, t cilat kshillohet t'i keni me vete pr t evituar riparaqitjen ose ekzaminimet shtes. Grat
shtatzana duhet t ken me vete ekzaminimin EKO me film dhe prshkrimin nga mjeku gjinekolog t moshs s
shtatzanis.
E rndsishme: Sipas Udhzimeve t Qendrs pr Parandalimin dhe Kontrollin e Smundjeve (CDC), juve mund tju
krkohet ti nnshtroheni analizave t mtejshme pr Tuberkuloz (TB), prgjigja e t cilave mund t marr 8-10 jav.
Seksioni Konsullor do t njoftohet me listn e aplikanve t referuar pr analizat e TB-s dhe ju nuk do t hasni
vonesa n ditn e intervists pr viz. Nse aplikanti rezulton pozitiv, ai ose ajo do ti nnshtrohet trajtimit t
detyrueshm t TB-s nga stafi mjeksor. Ju nuk do t paguani tarif tjetr pr trajtimin e TB-s.
Rezultatet e vizits mjeksore do t'i dorzohen n zarf t mbyllur dhe t vulosur vetm aplikantit, ose Seksionit
Konsullor. Ju NUK mund ta hapni zarfin. Hapja e zarfit bhet vetm nga npunsit e konsullats. Ju nuk duhet ta
drgoni n Ambasad CD-n e Rrezeve X, prve rasteve me azil. Juve do ju jepet nj kopje e formularit t vaksinave,
i cili mund tju krkohet pr t regjistruar fmijn n shkoll, etj.
Me firmosjen nga ana juaj t formularit mjeksor DS-2054 ju personalisht autorizoni dhe pranoni vizitn mjeksore.
Njoftim nga Seksioni Konsullor i SHBA-s: Data e skadimit t vizs suaj do t kushtzohet nga data e skadimit t
raportit mjeksor. Formulart mjeksor t klasifikuar si Class B (TB) jan t vlefshme pr 3 muaj nga data q e
firmos mjeku. T gjith formulart e tjer t klasifikuar si "Nuk ka smundje t dukshme" jan t vlefshm pr 6 muaj
nga data q e firmos mjeku. Nse rasti juaj kalon pr proces administrativ t mtejshm, apo shqyrtimi i rastit tuaj
vonohet pr shkak t dokumenteve q mungojn, raporti mjeksor mund t skadoj prpara se viza t lshohet. N
kt rast, juve do ju krkohet t kryeni edhe njher vizitn mjeksore dhe ta drgoni zarfin mjeksor n Seksionin
Konsullor prpara se ju t merrni vizn tuaj. Tarifa pr t rriturit (mosha 15 vje e lart) sht 145 Dollar dhe pr
fmijt nn moshn 15 vje sht 100 Dollar.
Pagesa e vizits mjeksore nuk kthehet pavarsisht nga rezultati i aplikimit tuaj pr viz emigrimi.
Shnim: Ju duhet t paraqiteni pr vizitn mjeksore n datn dhe orn e caktuar t takimit. Mos u paraqisni jasht
ditve prkatse dhe jasht orareve q ju jan caktuar, prve rasteve kur jeni udhzuar specifikisht nga Seksionin
Konsullor.
Personeli mjeksor nuk mban prgjegjsi pr vonesa n lidhje me shqyrtimin e dosjes s aplikantit n Zyrn
Konsullore t SH.B.A.-s.
UDHZIME PR VAKSINIMIN
N takimin e par t vizits mjeksore, aplikanti kryesor duhet t dorzojn kartelat personale t vaksinimit pr t
gjith personat q po aplikojn pr viz (T RRITUR DHE FMIJ), ku do t pasqyrohen imtsisht t gjitha vaksinat q
ata kan br q nga fmijria dhe deri n dit e vizits mjeksore. Kartelat e vaksinimit q pranohen t vlefshme
jan vetm ato q lshohen nga konsultort dhe qendrat shndetsore. Aty duhet t jen t dokumentuara emri,
atsia, mbiemri i personit, datlindja e sakt, datat e sakta t vaksinimeve dhe t rivaksinimeve (dita/muaji/viti).

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Consular Section, U.S. Embassy, Tirana

Last revised on 3/3/2015

Kartelat personale t vaksinimit do t jen t vulosura me vuln e konsultorit/qendrs shndetsore dhe t ken
vuln e mjekut q e lshon kt dokument. Vulat dhe emri i mjekut duhet t jen t lexueshme.
PR FARDO LLOJ ARSYEJE n qoft se n vizitn mjeksore nuk do t paraqisni karteln personale t vaksinimit ju
do t konsideroheni t pavaksinuar. N rast se n karteln personale t vaksinimit jan regjistruar datat e vaksinimit
vetm pr disa vaksina dhe vaksinat e tjera jan pa data (ju mund t pretendoni se jan kryer por nuk jan t
dokumentuara) kto t fundit do t konsiderohen t pakryera, pra ju do t konsideroheni t pavaksinuar me to.
Aktualisht vaksinimet q kryhen n Shqipri jan:
1) D.T.P. (Difteri / Tetanos / Pertuss)........
2) D.T. (Difteri / Tetanos) rivaksinim.........
3) Polio (Polimielit)...................................
4) Fruth ....................................................
5) Fruth Rubeol ...................................
6) Fruth Rubeol - Parotid ....................
7) H.V.B. (Verdhza) ................................
8) HiB .......................................................
9) Pneumokok ..........................................
10) Rotavirus
11) Meningococcal
12) Varicela

4 doza
2 doza
3 doza + dozat ekstra
1 doz
1 doz
1 doz
3 doza
3 doza
3 doza

Nj pjes e vaksinave t msiprme nuk aplikohen pr t gjitha moshat.

Nse pr nj nga arsyet e mposhtme:
- nuk jeni vaksinuar,
- nuk keni kryer vaksinat q kan ardhur vitet e fundit,
- nuk keni dokumentacion q vrteton q jeni t vaksinuar, apo
- dokumentacionin e keni t pjesshm, q vrteton q keni kryer vetm disa nga vaksinat,
prpara se t paraqiteni pr vizitn mjeksore ju kshillohet t kryeni dozn e par t do vaksine q ju nuk e keni
br ose pr t ciln nuk gjendet regjistri ose data kur e keni kryer. Nse keni filluar vaksinimin ose deri tani keni
kryer vaksinimin rregullisht, plotsoni rivaksinimin e rradhs. Regjistroni vaksinat n qendrn shndetsore ku i
kryeni.
Dokumenti i vetm q vrteton vaksinimin tuaj sht kartela personale tip e vaksinimit.
Prve ktij dokumenti vaksinimi, nuk do t njihet si i vlefshm asnj dokument tjetr. Krkoni dhe kontrolloni
vrtetsin e kartels tuaj t vaksinimit. Kartela personale e vaksinimit sht dokument zyrtar dhe personi q e
paraqet at prgjigjet personalisht pr vrtetsin e saj. Mos pranoni t merrni kartela vaksinimi dhe t regjistroni
vaksina q nuk i keni kryer ose pr t cilat aktualisht nuk ka regjistra, regjistra t cilt n rast verifikimi nuk do t
mund t vrtetonin se ju i keni kryer vaksinat.
Vaksinimet dhe rivaksinimet duhet t jen kryer ose t kryhen sipas skems s vaksinimit t aprovuar nga autoritetet
e Shndetit Publik t Republiks s Shqipris. N rast se pr kto probleme keni paqartsira, drejtohuni pran
Drejtorive t Shndetit Publik ose pran Drejtorive t Higjens dhe Epidemiologjis n rrethet prkatse.
Prve vaksinave t lartprmendura ju mund t keni kryer edhe vaksina t tjera jasht shtetit, t cilat mund t mos
ken nuk kan hyr n Shqipri dhe ju mund t'i keni kryer. Nse keni dokumentacion zyrtar pr to, duhet ta
paraqisni gjat vizits mjeksore.
Shnim: aplikantt q kan qen gjat 12 muajve t fundit n kto shtete: Pakistan, Siri, Guinea Ekuadoriale,
Afganistan, Etiopi, Irak, Izrael, Somali, apo Nigeri, duhet t sjellin prova t vaksinimit pr Poliomelit dhe t deklarojn
q kan qen n nj nga kto shtete pran stafit mjeksor.

11
Consular Section, U.S. Embassy, Tirana

Last revised on 3/3/2015

DEKLARAT MJEKSORE PERSONALE (Duhet plotsuar pr secilin aplikant t vizs)

Ju lutemi plotsoni kt formular dhe vendosni fotografin prpara se t kryeni vizitn mjeksore. Kt formular do
ta dorzoni si pjes e dokumentacionit tuaj shndetsor. Formulari sht pr nj person dhe plotsohet nga personi
q e firmos. Pr personat nn moshn 16 vje formulari plotsohet dhe firmoset nga prindrit.
Vendosni kryqet n kutin PO ose JO sipas gjendjes suaj shndetsore.
Fotografia

______________________ _______________ Mosha: ____ vje, Seksi: M

Mbiemri
Emri
Arsimi q keni kryer:

i mitur;

fillore;

8-vjear;

i mesm;

i lart

Profesioni q keni: _____________________________________________________

Pesha: _________ Kg;

PO

PO

JO

JO

Gjatsia: __________ cm

T PRGJITHSHME
Smundje ose dmtime q kan
krkuar shtrim n spital (prfshir
edhe psikiatriket)
A keni kryer ndrhyrje kirurgjikale
apo cezariane? Prshkruaji:

KARDIOLOGJIKE
Smudje t zemrs
Angina pectoris (infarkte,
parainfarkte)
Hypertension (tesion i lart i gjakut)
Aritmi t zemrs

PO

JO

PNEUMOLOGJI
A keni prdorur duhan
A prdorni duhan aktualisht
Azm
Smundje kronike obstruktive t
mushkrive (emfizem) Smundje
akute t mushkris.
A keni vuajtur nga tuberkulozi
A jeni trajtuar pr tuberkuloz?
A keni simptoma aktuale t
tuberkulozit

PO

JO

NEUROLOGJI & PSIKIATRI

A keni kaluar hemoragji ose ishemi
cerebrale
Epilepsi (smundja e toks)
Dmtime t aftsis pr t msuar,
t inteligjencs, t kujdesit vetjak,
t kujtess ose t komunikimit
rregullime mendore (depresion,
rregullimet Bipoilare, skizofreni,
prapambetje mendore)
Prdorim medikamentesh jasht
qllimeve mjeksore
Varsi ose abuzim me substanca*
specifike (droga). * amfetamina,
kanabis, kokain, halucinogjenet,
inhalantet, opioidet, fencikidinat,
sedative-hipnotike, anksiolitike
rregullime t tjera q lidhen me
prdorimin e substancave
(prfshir varsia ose abuzimi me
pijet alkolike)
Keni tentuar ndonjher
vetvrasjen?
A i keni shkaktuar ndonjher
dmtime SERIOZE personave t
tjer, keni kryer ndonjher
dmtime T MDHA t prons, ose
t keni patur probleme me
drejtsin pr arsye t gjndjes
shndetsore, ose nn ndikimin e
smundjeve mendore, alkolit ose
drogs?

12
Consular Section, U.S. Embassy, Tirana

Last revised on 3/3/2015

PO

JO

OBSTETRIKE & SMUNDJE

SEKSUALISHT T TRANSMETUESHME
Shtatzani?
Data e Parashikuar e Lindjes:

Difekte fizike t dukshme ose

keqformime (munges syri, gishta, dor,
kmb) jep sqarime:

_____________ (data-muaji-viti)

_________________________________

Smundje seksualisht t
transmetueshme, infeksione, synet (jep
sqarime):

_________________________________

________________________________
________________________________
PO

JO

ENDOKRINOLOGJI & HEMATOLOGJI

Diabet i sheqerit

Probleme t tjera q nuk jan

prmendur m lart por q krkojn
vmendje, trajtim mjeksor, ndrhyrje
kirurgjikale, etj. (jep sqarime):
_________________________________

Smundje t tiroides
_________________________________

T dhna pr malarie
PO

JO

T TJERA
Smundje malinje, kancere (jep
sqarime)
Smundje kronike t veshkave

PO

Hepatit kronik ose smundje t tjera

kronike t mlis
JO LEPRA
SMUNDJA HANSEN (Lepra)
Multibacilar
Trajtuar :
PO

A keni patur ose keni ankesa

shndetsore t tjera pr t cilat nuk
jeni sqaruar nga se vijn? (p.sh. rnie
n pesh, temperature e zgjatur, etj.)
(Nse PO prshkruani):
_______________________________
______________________________
A keni kryer shrbimin ushtarak?
Nse jo, jepni shpjegime:
-----------------------------------------------------

Paubacilar
JO

Probleme me Shikimin
Keni Kaluar Variceln (lija e dhenve)?
A keni patur grup invaliditeti?

GJENDJA CIVILE
Beqar
i/e ve

i/e martuar
Divorcuar

SHNIM: T gjitha problemet mjeksore duhet t shoqrohen me raportin mjeksor, epikrizn,

ekzaminimin, analizat, recetn e mjekimit, librezn shndetsore.
UN I NNSHKRUARI DEKLAROJ SE INFORMACIONI Q KAM DHN M SIPR SHT I SAKT DHE I
PRGJIGJET T VRTETS.
_____________________________________________________
EMRI
MBIEMRI
FIRMA
Data __________________

13
Consular Section, U.S. Embassy, Tirana

Last revised on 3/3/2015

Plotsoni informacionin e mposhtm, pavarsisht moshs

(Bni kopje t ktij formulari pr ta plotsuar secili aplikant i vizs)
Emri (Mbiemri, Emri)
Datlindja (muaj, dat, vit)

Gjinia

Numri i Pasaports

Numri i Dosjes

Vendlindja (Qytet, Shtet)

Shteti Ku Jetoni Aktualisht
Shteti Ku Keni Jetuar m Par
Adresa Aktuale ku Banoni
Qyteti Ku Jetoni Aktualisht
Kodi Postar i Rezidencs
Adresa Ku do t Jetoni n SHBA
Qyteti, Shteti dhe Kodi Postar ku do t Jetoni n SHBA
Kategoria e Vizs

Emigruese

Lotaria DV

Viza K (Fejese)

Birsim

NIV (Jo-Emigruese)

Viza 92 (Azil)

Numr Celulari
Adres e-maili
Emri i t gjith Fmijs/Fmijve (nse keni) dhe Datlindja e tyre (mm-dd-vvvv)
Emr Mbiemr

Ditlindje

1.
2.
3.
4.
5.
6.

14
Consular Section, U.S. Embassy, Tirana

Last revised on 3/3/2015