Patient Questionnaire for Immigration Exam
This form is used for Ezy Urgent Care patients. Your information will not be forwarded or used for any other reasons besides your Immigration Exam.
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PLEASE DO NOT PRINT THE I-693 FORM.
 Please do not bring your own copy. The I-693 and other forms will be provided on-site.

We accept card and cash for payment only. No checks. 
Last Name (as entered on Form I-485 or I-693) *
First Name (as entered on Form I-485 or I-693) *
Middle Name (if none, enter "N/A") *
Date of Birth *
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What Date is your appointment? *
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What Time is your appointment?
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Are you fluent in English? 
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Not fluent in English?
We do not offer any translators/interpreters on-site. 

Patients must bring their own translator/interpreter of their own respective language. The translator does not have to be certified. They may be family or friend but must be fluent in both English and the language they are interpreting. Translators/Interpreters must be physically present during the immigration exam. 

Exceptions includes Hmong speakers as majority of the staff are Hmong and may assist in translating. 

If you have questions, please call 651-646-0028
Have you already filed your Form I-485, the underlying application for Change of Status?
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Are you working with an Attorney for your Change of Status Process? *
Do you have an Interview Date or Request For Evidence Deadline?
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If Yes, What is the Date?
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If No, Do you have an expected completion date for the Form I-693?
Do you have medical insurance? *
We will NOT ACCEPT MEDICAL INSURANCE for this exam, but Vaccination options will be discussed at the time of the visit, and there are free or low cost places to get vaccinations if you do not have medical insurance.
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Gender *
Address: Street name, apartment/unit #  (as entered on Form I-485 or I-693) *
Address: City (as entered on Form I-485 or I-693) *
Address: State (as entered on Form I-485 or I-693) *
Address: Zip code (as entered on Form I-485 or I-693) *
City/Town/Village of Birth (as entered on Form I-485 or I-693) *
Country of Birth (as entered on Form I-485 or I-693) *
Alien Number (if any, Enter "N/A" if unknown) *
USCIS Online Account Number (if any, Enter "N/A" if unknown) *
Phone Number (No space, no dash) *
Email Address  *
Date of Arrival to the U.S. (MONTH/YEAR) *
Country of residence prior to the U.S. *
Visa Status *
Required
Results of last Tuberculin Skin Test (Mantoux) *
Date of last TB test, if known
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Have you ever been treated for active or latent tuberculosis? *
Have you ever had Chickenpox? *
Have you ever had Rubella? *
Have you ever had HIV? *
Have you ever had Leprosy? *
1. Have you ever had problems with your immune system? *
2. Do you have allergies? *
3. Did you have an organ transplant? *
4. Have you had any serious illnesses in the past? If yes, explain below. *
5. Do you currently have any sores on your genitals? *
6. Do you currently have any  swollen glands in your groin area? *
7. Do you currently have any abnormal discharge from your penis or vagina? *
8. How often do you drink alcohol? *
9. Do you take any medications regularly? If yes, explain below. *
10. Do you have any disabilities? *
11. Have you ever been diagnosed with a mental health illness?  If yes, please explain below. *
12. Have you ever been sick enough that your were in the hospital for longer than one day? If yes, please explain below. *
13. Have you ever been arrested for drunk driving? *
14. Have you ever been in jail or prison? *
15. Do you take any street drugs or prescription medicines that alter your thinking? *
16. Have you ever physically harmed yourself or another person? *
17. Are you taking any corticosteroid hormones? *
18. Do you currently have or have you ever had problems with the following:
Are there any medical problems that run in the family? If so, please list. (This includes things like parents with Diabetes or high blood pressure, etc.)
These questions below are for Women only:
When was your last menstrual Period?
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I don't know my last menstrual period.
Are you pregnant or possibly could be pregnant?
Do you use any form of birth control? If yes, please explain what kind.
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