Form I-693, Report of Immigration Medical Examination and Vaccination Record Completed Form Examples and Samples
Explore detailed examples and samples of a filled Form I-693, Report of Immigration Medical Examination and Vaccination Record. Learn how to accurately complete your immigration medical forms with our step-by-step guides and data mapping illustrations.
Example: Filling Form I-693, Report of Immigration Medical Examination and Vaccination Record
How this form was filled:
This example demonstrates how an AI can accurately extract clinical data, vaccination history, and personal identification from an unstructured patient intake summary. By processing the physician's narrative notes, the AI automatically populates the complex fields of Form I-693, ensuring that medical results like tuberculosis screening and vaccination status are correctly mapped, reducing manual data entry errors in immigration filings.
Source document used: Physician Medical Examination Summary
To whom it may concern, I am writing to summarize the medical evaluation for my patient, Mr. Alejandro J. Rodriguez, who is currently applying for adjustment of status. Alejandro resides at 452 Oak Street, Apt 3B, Springfield, IL 62704. He was born on January 12, 1990, in Mexico City, Mexico. His A-Number is A098765432. During his visit on February 15, 2026, he presented his Mexican Passport (Number: MEX8839201) as identification. We performed a routine immigration medical exam. His IGRA test (QuantiFERON) conducted on February 15, 2026, returned a negative result, and he is medically cleared for tuberculosis; no chest X-ray was required. Regarding his vaccination history, I reviewed the records he provided. He has completed the Tdap series, with the last dose recorded on March 10, 2023. He also completed his COVID-19 vaccination series (Pfizer-BioNTech) with the final dose received on December 5, 2024. He lacks documentation for Hepatitis B, so I administered the first dose of the Heplisav-B vaccine on February 15, 2026. Please let me know if you need further clarification regarding his physical exam findings; he is currently in good health with no class A or B medical conditions noted during the visit. Sincerely, Dr. Sarah Jenkins, MD, City General Clinic, 999 Medical Plaza, Suite 10, Springfield, IL 62701.
Information used to fill out the document:
- Applicant Details: Alejandro J. Rodriguez, born 01/12/1990 in Mexico City, A-Number A098765432
- Current Address: 452 Oak Street, Apt 3B, Springfield, IL 62704
- Identification: Mexican Passport #MEX8839201
- TB Screening: QuantiFERON negative, no chest X-ray required
- Vaccination Status: Completed Tdap and COVID-19; Hepatitis B dose 1 administered 02/15/2026
- Medical Clearance: No Class A or Class B conditions found
What this filled form sample shows:
- Automatic identification of A-Number and date of birth from prose
- Smart mapping of vaccine names to the correct form rows
- Context-aware logic for TB screening results
- Parsing of structured address data from a single narrative sentence
- Validation of identification document type and number
Form specifications and details:
| Form Name: | Form I-693, Report of Immigration Medical Examination and Vaccination Record |
| Edition Date: | 03/09/23 |
| Expiration Date: | 03/31/2025 |
| Agency: | U.S. Citizenship and Immigration Services (USCIS) |
| Primary Use: | Documenting medical examinations for immigration benefits |
| Categories: | immigration forms, Medi-Cal forms, medical forms, medical record forms, medical report forms, migration forms, VA medical forms |
| Created: | May 25, 2026 07:52 PM |