Fd 1065 Form PDF Details

The FD-1065 form serves a critical role within the framework of the Federal Bureau of Investigation, framed by its Revised date of July 27, 2011. Its primary purpose is to gather comprehensive medical history information, as authorized under 5 U.S.C. § 301 and 5 U.S.C. § 3301. This collection is deemed both relevant and necessary for ensuring the provision of appropriate medical care and for assessing an individual’s eligibility and/or fitness for duty. The significance of this form extends beyond mere data collection; it underscores a commitment to privacy and nondiscrimination, particularly emphasizing compliance with the Genetic Information Nondiscrimination Act of 2008 (GINA). GINA's guidelines prohibit the solicitation of genetic information, including family medical history, to prevent discrimination based on genetic factors. This form, while voluntary, is crucial in that incomplete submissions may impede or entirely prevent the necessary agency actions concerning medical care or employment continuation. The information gathered is maintained with confidentiality and protected under designated privacy acts, with disclosures governed by set routine uses. It encapsulates a range of personal and medical details—from basic identification and contact information to detailed medical history and current health status, explicitly designed to ensure that FBI personnel are medically and physically prepared for the duties ahead.

QuestionAnswer
Form NameFd 1065 Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesfd 1065 medical form, fd1065 medical form, how to form fd 1065, fbi 1065 pdf

Form Preview Example

FD-1065

Revised

7-27-2011

FEDERAL BUREAU OF INVESTIGATION

REPORT OF MEDICAL HISTORY

Privacy Act Statement: The collection of this information on this form, which is authorized by 5 U.S.C. § 301 and 5 U.S.C. § 3301, is relevant and necessary to provide appropriate medical care and to determine eligiblity and/or fitness for duty. Completion of this form is voluntary; however, your failure to supply all the information requested on this form may impede or preclude agency action regarding medical care or continued employment.

GINA Notice: Do Not Provide Genetic Information, Including Family Medical History

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. See 29 C.F.R. § 1635.8(b)(1)(i)(B).

This infomation is maintained in your medical file in the FBI Centeral records System, Justice/FBI-002, a description of which can be found at http://home.fbinet.fbi/DO/OGC/LTB/PCLU/PrivacyCivil%20Liberties%20Library/Forms/FBI002.aspx. This information may be disclosed in accordance with the routine uses referenced in this notice.

Date of Exam _______________

NOTE: This information is for official and medically-confidential use only and will not be released to unauthorized persons

1. Name of Patient (Last, first, middle)

2. Identification/67#

3. Grade

4. Division/Field Office Address

4a. Examining Facility

4b. City

4c. State

4d. Zip Code

5. Purpose of Examination

5a. Height

5b. Weight

6. Are you (Check One)

G Right Handed

G

Left Handed

7. STATEMENT OF PATIENT'S PRESENT HEALTH AND MEDICATIONS CURRENTLY USED (Use additional pages if necessary)

8. Present Health

8a. Current Medication

8b. Regular or Interm.

8c. Occupation

9. Allergies (Include insect bites/stings and common foods)

10. PAST/CURRENT MEDICAL HISTORY

Check Each Item

Household contact with anyone with tuberculosis

Yes

No

Don't Know

Check Each Item

Eye surgery to correct vision

Yes

No

Don't Know

Check Each Item

Swollen or painful joints

Yes

No

Don't Know

Tuberculosis or positive TB test

Blood in sputum or when coughing

Excessive bleeding after injury or dental work

Lack vision in either eye

Frequent or severe

 

headaches

 

 

 

 

 

 

Wear a hearing aid

 

 

 

 

 

 

 

 

 

Dizziness or fainting

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

spells

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wear a brace or back

 

 

 

 

 

 

 

 

 

Eye trouble

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

support

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check Each Item

Yes

No

Don't Know

Check Each Item

Yes

No

Don't Know

Check Each Item

Yes

No

Don't Know

Suicide attempt or plans

 

 

 

 

 

 

 

 

 

 

Stutter or stammer

 

 

 

 

 

 

 

 

 

 

Hearing loss

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sleepwalking

 

 

 

 

 

 

 

 

 

 

Scarlet fever

 

 

 

 

 

 

 

 

 

 

Recurrent ear infections

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wear corrective lenses

 

 

 

 

 

 

 

 

 

 

Inability to assume certain

 

 

 

 

 

 

 

 

 

 

"Trick" or locked knee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

positions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Severe tooth or gum

 

 

 

 

 

 

 

 

 

 

Rheumatic fever

 

 

 

 

 

 

 

 

 

 

Chronic or frequent colds

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

trouble

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sinusitis

 

 

 

 

 

 

 

 

 

 

Tumor, growth cyst, cancer

 

 

 

 

 

 

 

 

 

 

Foot trouble

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hay fever or allergic

 

 

 

 

 

 

 

 

 

 

Hernia

 

 

 

 

 

 

 

 

 

 

Nerve Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

rhinitis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Head injury

 

 

 

 

 

 

 

 

 

 

Hemorrhoids or rectal

 

 

 

 

 

 

 

 

 

 

Paralysis (including

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

disease

 

 

 

 

 

 

 

 

 

 

infantile)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Asthma

 

 

 

 

 

 

 

 

 

 

Frequent or painful

 

 

 

 

 

 

 

 

 

 

Epilepsy or seizure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

urination

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Shortness of breath

 

 

 

 

 

 

 

 

 

 

Bed wetting since age 12

 

 

 

 

 

 

 

 

 

 

Car, train, sea or air

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

sickness

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pain or pressure in chest

 

 

 

 

 

 

 

 

 

 

Kidney stone or blood in

 

 

 

 

 

 

 

 

 

 

Frequent trouble sleeping

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

urine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chronic cough

 

 

 

 

 

 

 

 

 

 

Sugar or albumin in urine

 

 

 

 

 

 

 

 

 

 

Depression or excessive

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

worry

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Palpitation or pounding

 

 

 

 

 

 

 

 

 

 

Sexually transmitted

 

 

 

 

 

 

 

 

 

 

Loss of memory or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

heart

 

 

 

 

 

 

 

 

 

 

diseases

 

 

 

 

 

 

 

 

 

 

amnesia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heart trouble

 

 

 

 

 

 

 

 

 

 

Recent gain or loss of

 

 

 

 

 

 

 

 

 

 

Nervous trouble of any

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

weight

 

 

 

 

 

 

 

 

 

 

sort

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

High or low blood

 

 

 

 

 

 

 

 

 

 

Eating disorder (anorexia

 

 

 

 

 

 

 

 

 

 

Periods of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

pressure

 

 

 

 

 

 

 

 

 

 

bulimia, etc.)

 

 

 

 

 

 

 

 

 

 

unconsciousness

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cramps in your legs

 

 

 

 

 

 

 

 

 

 

Arthritis, Rheumatism, or

 

 

 

 

 

 

 

 

 

 

X-ray or other radiation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bursitis

 

 

 

 

 

 

 

 

 

 

therapy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Frequent indigestion

 

 

 

 

 

 

 

 

 

 

Thyroid trouble or goiter

 

 

 

 

 

 

 

 

 

 

Chemotheraphy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Stomach, liver or

 

 

 

 

 

 

 

 

 

 

Sensitivity to chemicals,

 

 

 

 

 

 

 

 

 

 

Asbestos or toxic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

intestinal trouble

 

 

 

 

 

 

 

 

 

 

dust, sunlight

 

 

 

 

 

 

 

 

 

 

chemical exposure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gall bladder trouble or

 

 

 

 

 

 

 

 

 

 

Inability to perform certain

 

 

 

 

 

 

 

 

 

 

Plate, pins or rod in any

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

gallstones

 

 

 

 

 

 

 

 

 

 

motions

 

 

 

 

 

 

 

 

 

 

bone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Jaundice or hepatitis

 

 

 

 

 

 

 

 

 

 

Bone, joint or other

 

 

 

 

 

 

 

 

 

 

Easy fatigability

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

deformity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Broken bones

 

 

 

 

 

 

 

 

 

 

Loss of finger or toe

 

 

 

 

 

 

 

 

 

 

Been told to cut down or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

criticized for alcohol use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Adverse reaction to

 

 

 

 

 

 

 

 

 

 

Painful or "trick" shoulder

 

 

 

 

 

 

 

 

 

 

Diabetes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

medication

 

 

 

 

 

 

 

 

 

 

or elbow

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Skin diseases

 

 

 

 

 

 

 

 

 

 

Recurrent back pain or any

 

 

 

 

 

 

 

 

 

 

Used tobacco

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

back injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. FEMALE ONLY

Check Each Item

Yes

No

Don't Know

Date of Last

Menstrual

Period

Date of Last

Pap Smear

Date of Last Mammogram

Treated for a female disorder

Change in menstrual pattern

Check Each Item, If "Yes" Explain in Blank Space To Right. List explanation By Item Number.

Item

12.Have you been treated for a mental condition? If yes, specify when, where, and give details.)

13.Have you been denied life insurance? If yes, state reason and give details.)

14.Have you had, or have been advised to have, any operation? (If yes, describe.)

15.Have you been a patient in any type of hospital? (If yes, specify when, where, why, and name of doctor and complete address of hospital.)

16.Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the year, for other than minor illnesses?

17.Do you have a past or current medical history of any other condition not mentioned on this form?

18.Have you ever received, is there pending, or have you ever applied for pension or compensation for existing disability? (If yes, specify what kind, granted by whom, and what amount, when, why.)

Yes

No

19. Immunization

I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the doctors, hospitals, or clinics mentioned above to furnish the Government a complete transcript of my medical record for purpose of processing my application for this employment or service. I understand that falsification of information on Government forms is punishable by fine and/or imprisonment.

20. Typed or Printed Name of Examinee

20a. Signature

20b. Date

NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL OFFICER ONLY"

21.PHYSICIAN'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician shall comment on all positive answers in Item 7 through 11. Physicians may develop by interview any additional medical history deemed important, and record any significant findings here.

22. Typed or Printed Name of Physician or Examiner

22a. Signature

22b. Date

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fd 1065 form writing process described (step 1)

2. Immediately after this part is done, go to enter the applicable information in these - Allergies Include insect, Check Each Item, Yes, Dont Know, Check Each Item, Yes, Dont Know, Check Each Item, Yes, Dont Know, PASTCURRENT MEDICAL HISTORY, Household contact with anyone with, Tuberculosis or positive TB test, Blood in sputum or when coughing, and Excessive bleeding after injury or.

Check Each Item, Tuberculosis or positive TB test, and Check Each Item inside fd 1065 form

3. The next segment should be quite straightforward, Check Each Item, Yes, Dont Know, Check Each Item, Yes, Dont Know, Check Each Item, Yes, Dont Know, Suicide attempt or plans, Stutter or stammer, Hearing loss, Sleepwalking, Scarlet fever, and Rheumatic fever - all of these empty fields must be filled in here.

fd 1065 form writing process outlined (stage 3)

4. The next paragraph needs your details in the subsequent parts: Loss of memory or amnesia, Nervous trouble of any sort, Periods of unconsciousness, Xray or other radiation therapy, Chemotheraphy, Asbestos or toxic chemical exposure, Plate pins or rod in any bone, Easy fatigability, Been told to cut down or, Diabetes, Used tobacco, Palpitation or pounding heart, Heart trouble, High or low blood pressure, and Cramps in your legs. Be sure you give all of the needed info to go forward.

fd 1065 form completion process described (step 4)

5. The final step to conclude this PDF form is essential. Make sure you fill out the necessary fields, such as Treated for a female disorder, Change in menstrual pattern, Dont Know, Date of Last Menstrual, Period, Date of Last Pap Smear, Date of Last Mammogram, Check Each Item If Yes Explain in, Item, Yes, Have you been treated for a, Have you been denied life, Have you had or have been advised, Have you been a patient in any, and Have you consulted or been, before submitting. Failing to accomplish that can give you an incomplete and probably invalid document!

Stage number 5 of filling out fd 1065 form

A lot of people generally get some points wrong when completing Have you consulted or been in this area. Be sure to read again everything you type in right here.

Step 3: You should make sure your information is correct and press "Done" to proceed further. Try a free trial plan at FormsPal and acquire direct access to how to fd1065 - with all adjustments saved and available from your FormsPal account. FormsPal is focused on the privacy of all our users; we make sure that all personal data put into our tool remains confidential.

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