The US Immigration Medical Exam: What to Expect and What Disqualifies You

Every applicant for US lawful permanent resident status — whether adjusting status inside the United States through Form I-485 or consular processing abroad — must undergo an immigration medical examination to confirm that they are not inadmissible on health-related grounds under INA §212(a)(1). The exam is documented on Form I-693 (Report of Immigration Medical Examination and Vaccination Record), and for adjustment-of-status applicants it must be performed by a USCIS-designated civil surgeon. For consular processing applicants, the exam is performed by a panel physician designated by the local US embassy or consulate. The exam is not a general health check — it is a structured, regulated assessment of specific diseases, vaccinations, and mental health conditions that Congress has tied to admissibility. This guide walks through every element: civil surgeon selection, vaccination requirements, the four disease-specific tests, the mental health screen, and what does and does not disqualify you. The two-tier classification system — Class A and Class B conditions — determines whether your application proceeds, stalls, or is refused.

When the exam is required and which form applies

Form I-693 is required for nearly every adjustment-of-status applicant filing Form I-485. The statutory basis is INA §212(a)(1), which renders inadmissible any alien who is found to have a communicable disease of public health significance, who fails to present documentation of having received required vaccinations, who has a physical or mental disorder and behavior associated with the disorder that may pose a threat to the property, safety, or welfare of the applicant or others, or who is a drug abuser or addict. The implementing regulations are at 8 CFR §232.1 and 8 CFR §34.2, with technical standards in 42 CFR Part 34.

For consular processing applicants, the equivalent exam is performed by a panel physician designated by the Department of State. The technical standards are the same — the panel physician uses the same vaccination and disease-screening protocols — but the documentation is the DS-2054 (Medical Examination for Immigrant or Refugee Applicant) and related DS forms, not Form I-693. The exam is mandatory for immigrant visa applicants and for most refugee applicants; certain nonimmigrant visa categories (K-1 fiancé visas, for example) require a more limited exam.

The I-693 has a long-standing validity problem that was addressed in a major USCIS policy change in 2024. Previously, the form was valid for two years from the date the civil surgeon signed it, leading to re-exam requirements for applicants whose I-485 took longer than two years to adjudicate. Under the USCIS policy update effective 9 December 2024, an I-693 signed by a civil surgeon on or after that date does not expire — the applicant does not need to repeat the exam as long as the original is submitted with the I-485 application. Older I-693 forms signed before that date remain subject to the two-year rule, but most applicants can rely on the new indefinite validity if they file with a fresh exam.

Civil surgeons: who can perform the exam

Not every doctor can perform an immigration medical exam. USCIS designates civil surgeons under the authority of INA §232 and 8 CFR §232.1 — physicians who have applied for and received USCIS designation to perform I-693 exams. The designation requires the physician to be a licensed doctor of medicine (MD) or doctor of osteopathy (DO), to have a current, unrestricted state medical licence, and to complete the USCIS civil surgeon designation training. Designation is not automatic; a doctor must apply to the local USCIS field office, which reviews the application and grants or denies the designation.

The civil surgeon directory is published on the USCIS website at uscis.gov/tools/find-a-civil-surgeon. Applicants must use a designated civil surgeon — an exam performed by a non-designated physician will not be accepted, even if the physician is otherwise qualified. The directory is searchable by ZIP code and is updated regularly. Not all civil surgeons perform the full exam; some refer the vaccination and laboratory portions to outside providers, while others do everything in-house.

Fees are not regulated. Civil surgeons set their own fees, which vary widely — typically between $200 and $600 for the full exam, with additional fees for laboratory tests, vaccinations, and chest X-rays if needed. The State Department's panel physicians abroad charge similar amounts, which are paid by the applicant directly. USCIS does not cover any of these costs; the applicant pays out of pocket, and the fees are non-refundable even if the green card application is ultimately refused.

Vaccination requirements

The vaccination requirement is set out in INA §212(a)(1)(A)(ii) and 8 CFR §34.2(b). The specific vaccines required are those recommended by the Advisory Committee on Immunization Practices (ACIP) for the general US population, as adopted by the Centers for Disease Control and Prevention (CDC). The current required list, as of 2024, includes:

Applicants who have already received the required vaccinations should bring their vaccination records (childhood immunisation records, military records, prior immigration records) to the exam. Where records are incomplete, the civil surgeon can perform serology (blood tests) to confirm immunity for MMR, varicella, and hepatitis B — a positive IgG result substitutes for documentation of vaccination. Applicants who cannot document immunity and decline serology will be required to receive the missing vaccines, either from the civil surgeon or from a pharmacy before the exam is signed off.

Vaccine waivers: religious and moral objections

Two waiver paths exist for applicants who object to one or more required vaccines. The first is the religious waiver under INA §212(a)(1)(A)(ii)(II), available if the applicant's religious beliefs preclude vaccination. The applicant must demonstrate that the objection is based on religious belief (not philosophical, personal, or moral preference), that the belief is sincerely held, and that the belief would be violated by receiving the vaccine. The standard was tightened by policy guidance in 2020, and USCIS adjudicators now apply a stricter sincere-belief test.

The second is the moral waiver introduced by the Department of Homeland Security in 2024. This is available if the applicant's moral convictions preclude vaccination and the objection is based on a deeply held moral conviction (as opposed to a religious belief). The standard is similar to the religious waiver but applies to those whose objection is not anchored in any religion. Both waivers are filed on Form I-601 or as part of the I-485 application, depending on the circumstances.

Both waivers are discretionary, meaning USCIS can grant or deny them. The waiver applies only to the vaccination requirement — it does not waive the disease-screening requirements (TB, syphilis, gonorrhea). An applicant who receives a vaccination waiver is still subject to the full disease-screening portion of the exam. Waiver applicants should expect longer processing times and a higher rate of Requests for Evidence (RFEs).

Tuberculosis testing: TST or IGRA

All applicants aged 2 years and older must be screened for tuberculosis (TB) infection. The screening is performed using either the tuberculin skin test (TST) — also known as the Mantoux test, in which 0.1 mL of PPD tuberculin is injected intradermally and the induration is measured 48 to 72 hours later — or the interferon-gamma release assay (IGRA), a blood test that measures the immune system's reactivity to TB antigens. The CDC's 2021 Technical Instructions for Civil Surgeons for Tuberculosis allow either test, but the IGRA is preferred for applicants who have received the BCG vaccine (which is given in most countries outside the US and can cause false-positive TST results).

A positive TST or IGRA does not mean the applicant has active TB — it means they have been infected with TB at some point in their life. All positive screening results require a follow-up chest X-ray to rule out active pulmonary TB. If the chest X-ray is suggestive of active TB, the applicant must submit three sputum specimens (collected 8 to 24 hours apart) for acid-fast bacilli (AFB) smear and culture. Sputum cultures take 6 to 8 weeks to finalise, which is one reason a TB-positive exam can take months to resolve.

Applicants with latent TB infection (positive screen, normal chest X-ray, negative sputum if done) are not Class A. They are typically referred to their local health department or primary care physician for treatment with a course of antibiotics (usually isoniazid for 9 months or rifampin for 4 months), but treatment is not required before the green card can be approved. Applicants with active TB (positive sputum culture or clinical diagnosis) are Class A and must complete a full course of treatment — typically 6 to 9 months — before they can be cleared for adjustment of status.

Syphilis and gonorrhea screening

All applicants aged 15 years and older must be screened for syphilis and gonorrhea. For syphilis, the screening test is a nontreponemal serology test — typically the Rapid Plasma Reagin (RPR) or the Venereal Disease Research Laboratory (VDRL) test. A positive nontreponemal test is followed by a treponemal confirmatory test, such as the Treponema pallidum particle agglutination (TP-PA) assay or the fluorescent treponemal antibody absorption (FTA-ABS) test. The treponemal test confirms that the positive RPR reflects actual Treponema pallidum infection rather than a false positive (which can be caused by pregnancy, autoimmune disease, or recent vaccination).

For gonorrhea, the screening test is a nucleic acid amplification test (NAAT) on a urine specimen. The NAAT is highly sensitive and specific. A positive NAAT is followed by a confirmatory test before the applicant is classified.

Applicants with untreated syphilis (any stage) are Class A and must complete a full course of antibiotic treatment — typically a single intramuscular injection of benzathine penicillin G for primary, secondary, or early latent syphilis, or three weekly injections for late latent syphilis of unknown duration. Once treatment is documented, the applicant can be reclassified as Class B and the green card application can proceed. Untreated gonorrhea is similarly Class A; treatment with a single dose of ceftriaxone (typically 500 mg intramuscularly) plus azithromycin or doxycycline (for possible coexisting chlamydia) is curative, and the applicant is reclassified after documentation of treatment.

Applicants under 15 are not screened for syphilis or gonorrhea unless there is clinical suspicion of infection. The CDC's Technical Instructions also exclude screening for these diseases in applicants whose visa category or age makes infection unlikely.

Mental health screening

The mental health screening is one of the more nuanced parts of the I-693 exam. The civil surgeon evaluates the applicant for any current or past physical or mental disorder with associated harmful behavior that may pose a threat to the property, safety, or welfare of the applicant or others. The legal framework is INA §212(a)(1)(A)(iii), and the CDC's 2013 Technical Instructions for Mental Health Disorders set out the specific protocol.

The screen involves a structured history, mental status examination, and review of any available records. The civil surgeon asks about current and past psychiatric treatment, hospitalisations, suicide attempts, substance use, and any history of harmful behavior toward self or others. The exam is not a comprehensive psychiatric evaluation — it is a screen for admissibility-relevant conditions only. Anxiety, depression, and other common conditions are not in themselves disqualifying; the disqualifying standard is the combination of a mental disorder plus associated behavior that has caused or may cause serious harm.

Substance use disorders are a separate ground of inadmissibility under INA §212(a)(1)(A)(iv). A current diagnosis of substance use disorder (other than tobacco use disorder and caffeine use disorder) — including alcohol use disorder, when associated with harmful behavior — can result in a Class A designation. The civil surgeon evaluates for current substance use using the applicant's history, mental status examination, and laboratory tests where indicated (urine drug screen is not routinely required, but the civil surgeon may order one based on history or exam findings).

Class A conditions: what disqualifies you

Class A conditions are those that, under INA §212(a)(1)(A), render the applicant inadmissible on health grounds. A Class A designation does not mean automatic refusal of the green card — it means the applicant must be treated or granted a waiver before the green card can be approved. The five Class A categories are:

1. Communicable disease of public health significance. The current list, set by CDC regulation (42 CFR §34.2(d)), includes active tuberculosis (pulmonary or laryngeal), syphilis (infectious stage), gonorrhea, Hansen's disease (leprosy, infectious stage), pandemic flu, smallpox, and viral hemorrhagic fevers (Ebola, Lassa, Marburg, etc.). COVID-19 was on this list briefly but was removed in 2023.
2. Failure to present documentation of having received vaccinations against vaccine-preventable diseases. An applicant who has not received required vaccines and who has not been granted a waiver is Class A. This is the most common Class A designation and is easily cured — receive the vaccines and submit documentation.
3. Current physical or mental disorder with associated harmful behavior. The disorder must be "current" (active or in remission with risk of relapse) and must be associated with behavior that has caused or may cause serious harm. Past disorders with no current risk are not Class A.
4. Drug abuse or drug addiction. A current diagnosis of a substance use disorder (other than tobacco and caffeine) — typically using DSM-5 criteria — is Class A. This includes alcohol use disorder when associated with harmful behavior.
5. Failure to demonstrate ability to engage in gainful activity due to mental or physical disorder. This is a rarely-applied public-charge-style ground that applies only in extreme cases of incapacity.

Most Class A conditions are curable. Vaccination failure is cured by vaccination. Syphilis and gonorrhea are cured by antibiotics. Latent TB is not Class A (only active TB is). Substance use disorders can be cured by documented completion of a treatment program and sustained remission — typically at least 12 months of documented sobriety. The two hardest Class A conditions to clear are active TB (which requires 6 to 9 months of treatment) and serious mental disorders with harmful behavior (which require documented treatment and stability before a waiver can be sought).

Class B conditions: flagged but not disqualifying

Class B conditions are those that are not severe enough to render the applicant inadmissible but that the civil surgeon flags for follow-up after the green card is granted. Class B designations do not delay the green card approval; they simply note that the applicant has a condition that may require medical attention. Class B conditions include:

• Latent TB infection — positive screen, normal chest X-ray, no evidence of active disease. The applicant is referred to their primary care provider or local health department for evaluation and possible treatment.
• Syphilis in a non-infectious stage — for example, late latent syphilis that has been treated but whose treatment was not adequately documented.
• Chronic hepatitis B or C — not on the Class A list, but flagged for follow-up because of the risk of liver disease progression.
• Stable mental health conditions — for example, well-controlled depression or anxiety, treated and stable, with no associated harmful behavior.
• Other chronic conditions — diabetes, hypertension, hyperlipidemia, and other chronic conditions that warrant routine medical follow-up.

The Class B designation is informational — it does not affect admissibility, but it is noted on the I-693 form and may prompt the USCIS adjudicator to ask follow-up questions at the I-485 interview. Class B conditions do not require treatment before the green card can be approved, and the applicant is not required to demonstrate that they are receiving treatment. The designation simply flags the condition for the applicant's awareness and for the US public health system's record-keeping.

The sealed envelope rule

One of the most distinctive features of the I-693 process is the sealed envelope rule. The civil surgeon completes the I-693 form, places it in a sealed envelope, and signs across the seal. The applicant must submit the unopened envelope to USCIS with their I-485 application; if the envelope has been opened or tampered with, USCIS will reject the I-693 and require a new one. The rule is intended to prevent tampering and to maintain the integrity of the medical record.

Applicants should keep a copy of the I-693 for their own records before the civil surgeon seals the envelope — once sealed, the contents are not visible to the applicant. Civil surgeons typically provide a courtesy copy of the vaccination page (Form I-693 Supplement, "Vaccination Documentation") for the applicant's personal records, since this page is not subject to the sealed-envelope rule and is useful for future medical care.

For consular processing applicants, the equivalent rule applies: the panel physician seals the medical examination results in an envelope that the applicant must bring, unopened, to the consular interview. The consular officer opens the envelope; the applicant does not.

Takeaways

The US immigration medical exam is a structured, regulated assessment that screens for specific public-health-relevant conditions and confirms vaccination status. It must be performed by a USCIS-designated civil surgeon (for adjustment of status) or a State Department panel physician (for consular processing). The exam covers vaccinations (MMR, Tdap, varicella, flu, COVID, plus age-specific childhood vaccines), tuberculosis (TST or IGRA, with chest X-ray and sputum follow-up for positive results), syphilis (RPR with treponemal confirmation), gonorrhea (urine NAAT), and mental health (history and mental status exam, with focus on harmful behavior and substance use). Class A conditions — active TB, untreated syphilis or gonorrhea, current harmful-behavior mental disorders, drug abuse — render the applicant inadmissible but are typically curable with treatment. Class B conditions — latent TB, stable chronic conditions — are flagged for follow-up but do not delay approval. Bring complete vaccination records to the exam, accept that the process can take several weeks (longer if TB follow-up is required), and keep a copy of the I-693 vaccination supplement before the envelope is sealed. Once you have your green card, the five-year clock to naturalisation begins — track your physical presence with our US Citizenship Physical Presence Calculator to ensure you meet the 913-day requirement when you file Form N-400.