Items 1 to 6: patient and exam
Name, identification number, grade, home address, examining facility and purpose of examination.
SF93
Report of Medical History
- Agency
- GSA
- Revision
- Rev. 6/1996
- Fillable fields
- 307
- Pages
- 2
- Official source
- GSA form page
- Checked
- October 20, 2026
Standard Form 93 (SF 93): Report of Medical History
Standard Form 93 (SF 93), Report of Medical History, is a two-page medical record form printed as STANDARD FORM 93 (REV. 6-96). The form says it is Prescribed by ICMR/GSA and cites FIRMR (41 CFR) 201-9.202-1. GSA hosts it in its forms library, and GSA's page lists no authority or regulation.
The patient's name, identification number, grade, address, examining facility and purpose of examination open the form. The examinee then describes present health, current medication and allergies, checks a long list of past and current conditions Yes, No or Don't Know, and answers items 12 to 23 on matters such as employment, hospital stays, military service and immunizations. The examinee signs a certification, and a physician or examiner adds a summary.
The form says the information is for official and medically-confidential use only and will not be released to unauthorized persons. You can fill it out free in your browser on this page and download the result without an account.
What's on SF 93
Items 7 to 9: present health
Present health, current medication marked regular or intermittent, allergies including insect bites and stings and common foods, height, weight, occupation and whether right or left handed.
Item 10: medical history checklist
Conditions checked Yes, No or Don't Know, from tuberculosis contact and headaches to back pain, depression, alcohol use, illegal substances and tobacco.
Item 11: females only
Female disorders, changes in menstrual pattern, and the dates of the last menstrual period, Pap smear and mammogram.
Items 12 to 23: history questions
Employment or school problems for medical reasons, mental condition treatment, denied life insurance, operations, hospital stays, practitioners in the past 5 years, military rejection or discharge, disability pension or compensation, arrests or convictions, learning disability and immunizations.
Items 24 to 26: signatures and summary
The examinee's certification, name, signature and date, then the physician's summary and the physician's or examiner's name, signature and date.
How to complete SF 93
- 1
Fill in items 1 to 6
Enter the patient's name, identification number, grade, home address, the examining facility and the purpose of examination.
- 2
Describe present health
Complete items 7 to 9. For item 7, the form says to use additional pages if necessary.
- 3
Check each item
Mark Yes, No or Don't Know for every condition in item 10, and item 11 where it applies.
- 4
Explain each Yes
For items 12 to 22, the form says to explain each Yes in the blank space to the right and list the explanation by item number. Item 23 lists all immunizations received.
- 5
Sign the certification
Enter a typed or printed name, signature and date in item 24. The form says falsification of information on Government forms is punishable by fine and/or imprisonment.
- 6
Hand it to the doctor or nurse
The form says to hand it to the doctor or nurse, or if mailed, mark the envelope TO BE OPENED BY MEDICAL OFFICER ONLY.
Why fill Form SF93 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the GSA, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes and what the form says
Where it goes
The form says to hand it to the doctor or nurse, or if mailed, mark the envelope TO BE OPENED BY MEDICAL OFFICER ONLY. It prints no mailing address.
Confidentiality
The form says this information is for official and medically-confidential use only and will not be released to unauthorized persons.
Release of medical records
The certification authorizes the doctors, hospitals or clinics mentioned to furnish the Government a complete transcript of the medical record for processing the application for employment or service.
Edition and stock number
The form says previous edition not usable and prints NSN 7540-00-181-8368. It prints no OMB control number or Privacy Act statement.
Related forms
SF88
Medical Record - Report of Medical Examination
199 fields, 2 pages
SF504
Medical Record - History - Part 1
16 fields, 2 pages
SF505
Medical Record - History - Parts 2 and 3
21 fields, 2 pages
SF507
Medical Record
9 fields, 2 pages
SF600
Medical Record - Chronological Record of Medical Care
127 fields, 2 pages
SF601
Immunization Record
186 fields, 2 pages
Who fills out SF 93?
The form names the examinee and the physician or examiner.
Official sources and the blank
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Questions about Form SF93
Who issues SF 93?
The form prints Prescribed by ICMR/GSA and cites FIRMR (41 CFR) 201-9.202-1, Rev. 6-96. GSA hosts it in its forms library.
Who completes the physician's summary?
Item 25 is completed by the physician, who the form says shall comment on all positive answers in items 7 through 11 and may develop any additional medical history by interview.
What if I answer Yes to items 12 to 22?
The form says to explain each Yes in the blank space to the right and to list the explanation by item number.
How is SF 93 delivered?
The form says to hand it to the doctor or nurse, or if mailed, mark the envelope TO BE OPENED BY MEDICAL OFFICER ONLY.
Is the information on SF 93 kept confidential?
The form says it is for official and medically-confidential use only and will not be released to unauthorized persons.
What does signing item 24 authorize?
The certification authorizes the doctors, hospitals or clinics mentioned to furnish the Government a complete transcript of the medical record for processing the application for this employment or service.
Can an older edition of SF 93 be used?
The form says previous edition not usable.