The Four Components of the Immigration Medical Exam

The immigration medical exam (Form I-693) has four distinct components, each governed by USCIS Technical Instructions. Attorneys who understand each component can better prepare their clients, anticipate potential findings, and identify issues that may require follow-up before the case reaches USCIS.

The four components are: (1) physical examination, (2) mental health screening, (3) vaccination review, and (4) required laboratory testing. Each component maps to specific grounds of inadmissibility under the Immigration and Nationality Act (INA).

Component 1: Physical Examination

The physical examination covers all major organ systems: cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurological, and dermatological. The civil surgeon is looking for communicable diseases of public health significance — the primary physical ground of inadmissibility.

Communicable diseases of public health significance currently designated by the U.S. Department of Health and Human Services include tuberculosis, gonorrhea, syphilis, chancroid, granuloma inguinale, lymphogranuloma venereum, and Hansen's disease (leprosy). HIV was removed from the list in 2010 and is no longer a ground of inadmissibility.

The civil surgeon will also review the applicant's medical history, including chronic conditions, prior surgeries, hospitalizations, and current medications. Chronic conditions that are not communicable diseases are generally not grounds of inadmissibility.

Component 2: Mental Health Screening

The mental health screening is not a comprehensive psychiatric evaluation. It is a focused assessment to determine whether the applicant currently has a physical or mental disorder associated with harmful behavior — behavior that poses a threat to the property, safety, or welfare of the applicant or others.

This is a narrow legal standard. Having a mental health diagnosis — including depression, anxiety, PTSD, ADHD, bipolar disorder, or schizophrenia — does not automatically create a ground of inadmissibility. The civil surgeon must find that the condition is currently associated with harmful behavior.

Attorneys should advise clients to disclose mental health history honestly. Concealment creates far greater risk than disclosure. The civil surgeon's role is not to penalize mental health treatment — it is to assess current safety.

Component 3: Vaccination Review

The vaccination review is one of the most common sources of delays and RFEs. USCIS requires applicants to have received all vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) that are age-appropriate and medically appropriate.

Required vaccines include MMR, varicella, hepatitis A, hepatitis B, influenza, meningococcal, pneumococcal, Tdap/Td, HPV (age-appropriate), COVID-19, and others. The civil surgeon reviews the applicant's vaccination records and administers any missing vaccines at the time of the exam.

Foreign vaccination records are accepted if they are in a format the civil surgeon can verify. Attorneys should advise clients to bring all available vaccination documentation — including foreign records — to the appointment. Missing records can require re-vaccination, which adds cost and time.

Component 4: Laboratory Testing

Required laboratory tests include tuberculosis screening (TST or IGRA), syphilis serology (RPR), and gonorrhea culture (for applicants 15 and older). Additional tests may be required based on the applicant's medical history or the civil surgeon's clinical judgment.

TB testing is the most clinically significant laboratory component. A positive TST or IGRA triggers additional evaluation, including a chest X-ray. Depending on the findings, the applicant may receive a Class A (active TB, inadmissible) or Class B (inactive TB or TB-related findings, admissible with follow-up) designation.

Attorneys should be aware that laboratory results can take several days to return. The civil surgeon cannot complete Form I-693 until all required test results are available. This affects scheduling and case timelines.

Form I-693 Completion and the Sealed Envelope

After completing all four components, the civil surgeon completes Form I-693 and seals it in an envelope. The applicant must deliver the sealed envelope to USCIS — either at an interview or by mail, depending on the case type. The envelope must remain sealed; opening it invalidates the exam.

The civil surgeon's signature and stamp on the sealed envelope are critical. Attorneys should verify that the envelope is properly sealed and stamped before the client leaves the office. A missing stamp or broken seal is a common cause of RFEs.

Grounds of Inadmissibility the Civil Surgeon Can Trigger

The civil surgeon's findings can trigger three grounds of inadmissibility: (1) communicable disease of public health significance (INA § 212(a)(1)(A)(i)), (2) failure to present documentation of vaccination (INA § 212(a)(1)(A)(ii)), and (3) physical or mental disorder with associated harmful behavior (INA § 212(a)(1)(A)(iii)).

A Class A finding on any of these grounds makes the applicant inadmissible unless a waiver is granted. A Class B finding (for TB) does not create inadmissibility but requires follow-up treatment after admission. Attorneys should understand the distinction between Class A and Class B findings when advising clients.