U.S.

Department of State Academic Exchanges

Participant Medical History and Examination Form

Having been selected to participate in a U.S. Department of State international educational exchange program, you are required to submit
a completed Medical History and Examination Form. The attached form should be completed and returned to:

Participants will complete Parts I, II, III, and IV prior to the medical examination. If the space provided is not sufficient, you may attach
additional pages. Parts V, VI, VII, and VIII must be completed by a qualified, licensed physician, doctor, or nurse practitioner no more than
six (6) months before your grant start date.

The purpose of this form is to confirm health status and plans for continuing care in your host country, as well as for medical clearance,
upon which a grant is contingent. The information will also help Fulbright program staff be of maximum assistance to you should the need
arise while you are on program. Mild physical or psychological disorders can become serious under the stresses of life in an unfamiliar
environment. It is important that program administrators in the U.S and abroad be made aware of any medical, psychological, physical, and
emotional condition(s), past or current, which might affect you while on your program.

The Medical Examination History (Part VI), Medical Examination Report (Part VII), and Physician’s Statement (Part VIII) must be
completed in English by a licensed physician, doctor (MD, DO, or foreign equivalent), or nurse practitioner (NP) who is not a member of
your family and returned to your program staff before your participation in the program can be confirmed. Violation of this policy may
result in termination or revocation of your award. If the form is completed by a physician’s assistant or registered nurse (RN), it must be
cosigned by a licensed physician, doctor, or nurse practitioner.

Failure to disclose your current medical issues or medical history to your medical examiner may result in termination or revocation of your
grant.

If there are any significant changes in your medical, psychological, physical, or emotional condition(s) after you submit your Medical History
and Examination Form, you must notify your Fulbright program administrator.

Your award is contingent upon your submitting the Medical History and Examination Form by stated deadlines and remains contingent
until the information is reviewed and satisfactory medical clearance is issued.

INSTRUCTIONS TO PARTICIPANTS
In advance of your medical examination:
• Complete Parts I, II, III, and IV on your own prior to the physical examination.
• If the space provided for further explanation is not sufficient, you may attach additional pages. Be sure to note this in the response
box, e.g., continued on a separate page.
• Familiarize yourself with the instructions to the physician.
• Understand the scope of the clinical examination and the tests required for your age and/or known condition so that you can
be sure that the requirements of the form will be met.

At the time of your medical examination:

• Ensure that your health is evaluated in Parts VI and VII and that the form is signed by a licensed physician, doctor, or nurse
practitioner. (Although medical offices sometimes use a physician's assistant to help perform the examination and tests, only a
licensed physician, doctor, or nurse practitioner may sign the form.)
• Ask your medical examiner to return the completed report, including his/her signature and title, and test results to you as soon as
possible.
• Check the form to make sure that Parts VI, VII, and VIII have been completed by your medical examiner. If the form is incomplete,
illegible, or if the results of the required tests are not reported, Fulbright program staff will return the form to you. This step costs
time and may require a return visit to your medical examiner. Please prevent such delays.

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Following the medical examination:
• Compile your medical report to include pages 2-11. Insert additional statements and test results following the relevant pages.
• Sign and date the form on page 11.
• Scan the entire report into a single PDF or JPG document. These are the only acceptable upload formats.
• Ensure that your scan is legible, complete, and in the correct order before uploading.
• Name your scanned document: Nominating Country-Last Name-First Name-MedForm (example: Vietnam-Jones-John-MedForm)
• Return document to your home country Fulbright Office per their instructions that were provided to you separately.

PART I: PARTICIPANT BACKGROUND AND CONTACT INFORMATION: To be Completed by Participant

For Parts I-IV, please type or print in ink and print prior to medical examination.

NAME: Cediel Escobar Judith Cristina

Last First Other

DATE OF BIRTH: 12/13/1995 __ SEX: Female

Month/Day/Year
PRESENT ADDRESS:
Calle 9c # 22-34 Cali Colombia
Home or Residence City Country

GRANT LOCATION: Gainesville GRANT DATES:

(If known) City/Country 08/2024 05/2028
From To

Will you be covered by private health insurance while on your program? Yes No

If yes, complete the following information. As well, please confirm with your provider that your coverage extends to your time overseas
for your award. Be aware your existing coverage will remain your primary insurance for the duration of your grant.

Name of Health Plan/ Health Care N/A

Provider:

Health Plan ID#: N/A

Health Plan Effective Date: N/A

Health Care Provider Address:

N/A

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Please provide the names of medical professionals consulted within the last 3 years, except for routine physical examinations. List
your primary care physician as well as any specialists. (Submit an additional form as needed).

NAME SPECIALTY or Primary Care TELEPHONE #:

Primary Care Physician
Mónica Fernandez General +573122985912

William Sánchez Psychiatry +573214216155

EMERGENCY CONTACT INFORMATION AND MEDICAL PROXY: To be Completed by Participant

Name two individuals to notify in case of emergency.

PRIMARY EMERGENCY CONTACT: SECONDARY EMERGENCY CONTACT:

Name: María Cristina Escobar Castro Name: Cristian Matallana Castellanos
Address: Address:
Carrera 29 # 5a-42
Calle 9c # 22-34
Cell phone number: +573183887665 Cell phone number: +3014358227
Home number: N/A Home number: N/A
Office number: N/A Office number: N/A
Email: [email protected] Email: [email protected]

While your academic exchange program does not require that you have established a medical proxy – a medical proxy is an individual
who is informed of and can make decisions about your medical wishes on your behalf if you are unable – it is strongly recommended that
you consider this option for any emergency medical situations that may result while you are abroad. Should you already have a
designated medical proxy, please indicate him/her below and provide a copy of the supporting documentation along with your medical
examination results.

If you have a legal medical proxy, indicate him/her here and provide a copy of documentation. (Most U.S. states have forms for the
purpose of designating a medical proxy.):
MEDICAL PROXY CONTACT (Optional):
Name:
N/A
Address: N/A

Cell phone number:

N/A
Home number: N/A

Office number:
N/A
Email:
N/A

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 PART II: PARTICIPANT MEDICAL HISTORY: To be Completed by Participant
To be completed by the participant prior to the Medical Examination.

Have you ever been diagnosed with/treated for any of the following conditions? Please indicate by answering YES or NO.
YES answers must be explained in the space below, indicating dates, nature of diagnosis and treatment, as well as the current status.
Attach additional pages if necessary. Further explanation may be required in Part VI which is completed by the medical examiner.

For any items checked “Yes,” the physician may recommend a test to allow for further explanation of the current status of the condition
and/or the prognosis or outcome.

MEDICAL HISTORY
CHECK EACH ITEM
YES NO YES NO
Frequent or severe headaches
X
Fainting spells (syncope)
X
Epilepsy or seizures Heart condition incl. arrhythmia, angina, heart
X attack, murmur, and heart failure X
Stroke Eye disease or vision impairment (other than
X corrected refractive error) X
Hearing impairment Severe allergies, including environmental,
X insect stings, food, and medication X
X
Tooth or gum disease (periodontal disease) Tropical diseases, incl. malaria,
X amoebiasis, leprosy, filariasis, etc.

X
Asthma, emphysema, persistent cough, or other Severe skin disorder
lung conditions X
Tuberculosis HIV infection, AIDS
X X
High blood pressure Cancer in any form
X X
X
Gynecological disorder Depression, anxiety, excessive worry, or
X related condition
Hormonal disorders, incl. thyroid
X
Schizophrenia, psychosis, bipolar disorder, or
related condition X
Diabetes mellitus (high blood sugar, sugar in urine)
X
Anorexia, bulimia, obsessive-compulsive
disorder or related condition X
Sickle cell anemia, excessive bleeding, blood clots or
other blood disorder X
Drug or alcohol abuse
X
Please explain any items above to which you answered YES, as well as any other health conditions (medical, psychological, physical,
and emotional) you have experienced in the last three (3) years. Please include diagnosis, dates of occurrence, type and dates of
treatment, medications, outcome, and current status. Attach additional pages if necessary.

Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) for two years.

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 PART III: VACCINATION HISTORY: To be Completed by Participant
To be completed by the participant prior to the Medical Examination. NOTE: COMPLETION OF THIS SECTION IS RECOMMENDED, BUT NOT
REQUIRED. IT IS THE PARTICIPANT'S RESPONSIBILITY TO DETERMINE ANY TEST SPECIFICALLY REQUIRED BY THE HOST COUNTRY. If exact
dates of immunizations are not known, list month and year or just year.

Below are the generally recommended vaccinations for foreign participants traveling to the United States only. Individuals are advised to
consult the CDC travel website: http://wwwnc.cdc.gov/travel/destinations/list
POLIO (Three or more doses) Dates of immunization: During childhood

DIPHTHERIA, PERTUSSIS, TETANUS Dates of immunization:

(Three or more doses, one within the past 10 years)
12-04-2015
MEASLES – MUMPS – RUBELLA (MMR) (Or list individual Measles, Date of immunization:
Mumps, and Rubella immunizations below)
09-04-2015 29-04-2024
MEASLES Dates of Live Immunization (two required, at least one First immunization date:
month apart)
Second immunization date: N/A
(or) Indicate date of disease
(or) Indicate date and results of measles titer (or) Date of Disease:
(or) Date and result of measles titer:

MUMPS Dates of Immunization (two required, at least one month First immunization date:
apart)
Second immunization date: N/A
(or) Indicate date of disease
(or) Indicate date and results of mumps titer (or) Date of Disease:
(or) Date and result of mumps titer:

RUBELLA Dates of Immunization (two required, at least one month First immunization date:
apart)
(or) Indicate date and results of rubella titer Second immunization date:
Note: History of disease is not acceptable proof of immunity to N/A
rubella (or) Date and result of rubella titer:

COVID-19 Vaccinations First Dose details: Pfizer 04-30-2021

(Please list manufacturer and date for each dose)
Second Dose details: Pfizer 05-21-2021

Other Dose details: Moderna 01-07-2022

Booster / Add’l Doses:

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 PART IV: PLAN FOR CONTINUING CARE WHILE ON GRANT: To be Completed by the Participant

To be completed by the participant prior to the Medical Examination.

It is important that you consider how you will manage your medical, psychological, physical, and emotional health needs while overseas.
If you have a condition that requires ongoing care (e.g. monitoring or testing, maintenance medication, medical devices or supplies) you
must plan in advance to safeguard your wellbeing.

You should ensure that you understand the Accident and Sickness Program for Exchanges (ASPE), which is a limited health benefit plan
provided to exchange participants while on program in their host country. Please review the ASPE Benefits Guide available at
https://www.sevencorners.com/about/gov/usdos, including the following sections:
• Benefit Coverage, beginning on page 9
• Benefit Exclusions, beginning on page 12
• Inside the U.S.: Medical Provider Network, found on page 15
• Inside the U.S.: Prescription Drugs, beginning on page 17
• Mental Health & Crisis Support Hotline, found on page 21

You should evaluate your specific health needs to determine whether you need to continue your current health insurance coverage
and/or garner additional health insurance coverage while overseas, in addition to ASPE coverage.

Please provide evidence of your advanced planning by responding to the questions below. If the space provided is not sufficient, you may
attach additional pages.

1. If you plan to regularly meet with a health care provider or mental health professional while on grant, please specify what type of
provider (e.g. neurologist, oncologist, psychiatrist, etc.), the condition being treated, and the anticipated frequency of appointments.
Psychologist and psychiatrist

2. Please list any testing, medications, medical devices, and/or medical supplies, support, resources, etc. that you will require while on
grant and the condition for which they are needed (such as diabetes, high blood pressure, anxiety, bipolar disorder, depression, low
vision, etc.).
Atomoxetine 80mg for ADHD

3. Detail your plans for securing the care specified above in questions 1 and/or 2 while in the United States. (Due to regulations regarding
controlled substances and/or prescription medications, drugs available overseas are not necessarily available in the United States. For
more information refer to the ASPE Benefits Guide.)

Bring the approved amount for travel and request an appointment with Psychiatry and Psychology
as soon as you arrive at the University through the University Care System,
which has a free service for students.

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 PART V: INSTRUCTIONS FOR THE MEDICAL EXAMINER

The individual you are examining plans to participate in an international educational exchange program and intends to reside in the United
States for an extended period of time. Some locations are remote and may have limited medical support from doctors, nurses, laboratory
facilities and hospitals. You are asked to carefully consider the applicant’s general fitness and medical, psychological, physical, and
emotional health as it relates to successful completion of the exchange program.

Please evaluate thoroughly all items listed above in Part II: PARTICIPANT MEDICAL HISTORY, Part III: VACCINATION HISTORY, and Part
IV: PLAN FOR CONTINUING CARE WHILE ON GRANT. It is most important that you:
• Discuss medical history with the participant, conduct a general medical examination, and respond to the questions on pages 8,
9, and 10.
• If the space is not sufficient for a thorough explanation, you may attach additional pages.
• Enter N/A in the space if the question is not applicable to the participant.
• There are no specific laboratory tests required, although the exchange program may request further testing based on the
participant’s medical history. Physicians are encouraged to obtain appropriate tests as indicated by the medical history and
results of the physical examination or place of grant activity. For example, G6PD for participants in malarial areas, recent blood
sugar determination for diabetic patients or CD4 counts for patients with HIV infection.
• Order and record (or attach copies of) all relevant laboratory tests or necessary data. If there are test results within the past
twelve months, please also attach.
• After completing the medical examination, record all findings on pages 8, 9, and 10. Only the results of a physical exam
performed no more than six (6) months prior to the grant start date may be reported.
• Comment on all indicated follow-up examinations and conditions that may require frequent observation or prolonged
treatment. Please indicate your overall opinion of the examinee’s health on page 11.
• Sign and date page 11.

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PART VI: MEDICAL EXAMINATION HISTORY: To Be Completed by Medical Examiner
1. If the participant answered “YES” to any of the conditions listed in the medical history in Part II, please discuss with participant
and comment below. Include dates of occurrence, treatment and outcome, if not indicated in the participant’s explanation, and
if and how the condition may impact participation in the program abroad.

2. Has the participant ever had any significant or serious illness or injury not mentioned in the medical history? If so, explain the
nature of the problem and outcome.

N/A

3. Please explain any operations (surgical procedures) the participant has had that may impact the participant’s experience on the
program.

N/A

4. Has the participant ever been hospitalized for any reason? If so, list the condition(s), provide dates of treatment, and explain the
outcome.

N/A

5. Has the participant ever seen a psychiatrist, psychologist, or psychotherapist? If so, list the condition(s), provide dates of
treatment, and explain the outcome.

Yes. Diagnosed with Attention Deficit Hyperactivity Disorder two years ago.
Maintains pharmacological treatment from psychiatry with Atomoxetine 80mg
and therapeutic accompaniment with psychology.

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 PART VII. MEDICAL EXAMINATION REPORT: To be Completed by Medical Examiner
THIS MEDICAL EXAMINATION REPORT MUST BE COMPLETED IN ENGLISH BY A DESIGNATED AND LICENSED PHYSICIAN, DOCTOR, OR NURSE
PRACTITIONER AFTER REVIEWING THE EXAMINEE’S MEDICAL HISTORY (PART II) AND PLAN FOR CONTINUING CARE WHILE ON GRANT (PART
IV), CONDUCTING A PHYSICAL EXAMINATION, AND ASSESSING LABORATORY AND X-RAY RESULTS. THE MEDICAL EXAMINER MUST
COMMENT ON ALL POSITIVE AND/OR SIGNIFICANT FINDINGS IN THE SPACE PROVIDED.

Note: Results of tests and X-rays included in this medical evaluation must be no more than six (6) months prior to the date of the participant’s
arrival in the United States.

Please type or print in ink.

PARTICIPANT’S NAME: Cediel Escobar Judith Cristina

Last First Other

HEIGHT: (in or cm) 1.65 cm WEIGHT: (lb or kg) 66 kg

BLOOD PRESSURE: Syst./diast. RESTING HEART RATE:

CLINICAL EVALUATION
Please provide an answer to each item.
Abnormal findings must be fully explained in the space provided. Attach additional pages if needed.
NORMAL ABNORMAL DESCRIBE ABNORMAL FINDINGS
Head and neck
Hearing Acuity The patient shows mild lumbar disocombex
escoleosis, which was previously corroborated
Visual Acuity (with corrective lenses, if used) by X-rays performed.
Lungs and chest The patient reports having sporadic pain peaks,
for which she is doing constant strengthening.
Heart and vascular system Additionally, she has a diagostic of ADHD,
Abdomen which is under control.
Breasts
Genito-urinary/Gynecologic
Musculoskeletal
Lymphatic
Neurologic
Skin
Psychiatric

A test for TB is required (for foreign grantees) at the time of examination, regardless of prior BCG vaccination. The PPD skin test or
interferon gamma release assay blood test is acceptable. PPD skin test results over 10mm require a chest X-ray. An abnormal result on
either test mandates a chest X-ray to evaluate for active tuberculosis.

Tuberculin Skin Test (PPD) Result (millimeters of induration): 0 Pos Neg

Date of test: 04-29-2024

OR
IGRA Test Date: Pos Neg

Chest X-ray (if required) Date:

Chest X-ray findings:

(Note to Physician: X-ray images need not be submitted on film or otherwise)

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There are no specific laboratory tests required, although the exchange program may request further testing based on an applicant’s
medical history. Medical examiners are encouraged to obtain appropriate tests as indicated by the medical history and results of the
physical examination or place of grant activity (e.g., G6PD for malarial areas). For example, a diabetic patient should have a recent blood
sugar determination or patients with HIV infection should obtain a CD4 count.

NOTE: IT IS THE GRANTEE'S RESPONSIBILITY TO DETERMINE ANY TEST SPECIFICALLY REQUIRED BY HIS/HER HOST COUNTRY.

1. List all the medications taken by the participant in the past two (2) years.
Atomoxetine
Acetaminophen
Omeprazole
Diclofenac

2. List all specific medications (generic or name brand) currently being taken by the participant, whether on a regular or as needed basis.
Atomoxetine

3. List all medical devices being used by the participant (e.g. CPAP machine, glucose monitor, prosthesis, etc.).
N/A

4. List any laboratory tests administered as part of this medical examination. Indicate type of, and reason for, test and the results. Attach
additional information or documentation where appropriate.
N/A

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 PART VIII: PHYSICIAN’S STATEMENT: To be Completed by Licensed Physician, Doctor or Nurse Practitioner
Based on your physical examination and on the participant’s medical, psychological, physical, and emotional history, including Part IV: Plan
for Continuing Care While on Grant, do you consider the participant able to study, teach or conduct research in the location indicated on
page 2 of the form?

(Circle one) Yes No Conditional

If No or Conditional, please explain:

PERSON COMPLETING THE PHYSICAL EXAMINATION:

Name Position Date

Signature of Examining/Supervising Licensed Physician, Doctor, or NP (not electronic):

Date:

Name of Examining/Supervising Licensed Physician, Doctor, or NP including credentials:

Telephone number: Email address:

Address:

PART IX: PARTICIPANT'S STATEMENT: To be Completed by Participant

I certify that I have reviewed the information entered in Parts I, II III, and IV and have discussed subsequently with a licensed physician,
doctor, or nurse practitioner the information in Parts VI, VII and VIII. This information is true and complete to the best of my knowledge.
I acknowledge that falsifying or knowingly excluding critical medical or psychological information may jeopardize my participation in this
international educational exchange program. Furthermore, I understand that if any of this information is found to be substantially
inaccurate or incomplete, it may result in my return home. Failure to disclose my current medical issues or medical history to my medical
examiner may result in termination or revocation of my grant.
Prior to departure I understand that I must immediately notify the Post or Fulbright Commission of any changes in my medical status or
overall health and wellness. During the grant, I must immediately notify the Institute of International Education (IIE) of any change in my
medical status.
I am aware that the information in this form and any attachments (e.g., laboratory test results, X-rays, etc.) will be provided to my
administrating agency to help Fulbright program staff be of maximum assistance should the need arise while I am on program.
In the event of a medical emergency or serious illness during the grant program, I authorize release of my medical records to the U.S.
Department of State or its designated contractual agency.

Signature (not electronic): Date:

Privacy Policy: The information provided by you and your medical examiner will remain confidential and will be responsibly shared
with appropriate professionals for grant administration purposes only.
Revision date: February 1, 2024

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