Although furnishing this information is voluntary, individuals who fail to submit this form or who do not provide all the requested information may be denied a visa or experience processing delays.
Eligibility: the Department of State uses the information provided on this form to determine an individual's eligibility for a visa.
Hansen's Disease: complete only if the applicant was diagnosed by the panel physician or was on treatment at the time of presentation for their medical examination.
Release: the information provided may also be released to federal agencies for law enforcement, counterterrorism and homeland security purposes.
Visa records: INA Section 222(f) provides that visa issuance and refusal records shall be considered confidential.
| Question | Answer |
|---|---|
| Form Name | Form DS-3026 |
| Form Length | 3 pages |
| Fillable? | Yes |
| Fillable fields | 266 |
| Avg. time to fill out | 45 min |
| Edition | 02-2022 |
| Issuing agency | U.S. Department of State |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | DS-3026, DS3026, DS 3026, Form DS-3026, Medical History and Physical Examination Worksheet |
| Official source | Form DS-3026 (Rev 02-2022), U.S. Department of State |
Form Ds 3026 isn’t the one you’re looking for?