Preparation of a Medical File
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1 European Central Bank Directorate General Human Resources ECB s Medical Adviser c/o Medical Centre Snemannstrasse 20 D Frankfurt am Main Preparati of a Medical File The results of the medical examinati must be less than e mth old. No applicant for a positi at the European Central Bank may be recruited unless the ECB s Medical Adviser certifies that he/she satisfies the standards of general health and physical fitness required to carry out the duties envisaged. Would you please, before you take up your appointment: Arrange to be examined by your doctor, requesting him/her to fill in the attached Medical Examiner s Report and to return it (sealed in a separate envelope) to the ECB s Medical Adviser s address given above; or Bring the attached Medical Examiner s Report with you to the appointment arranged with the ECB s Medical Adviser (in case you are local). The ctent of the Medical Examiner s Report is protected by medical secrecy. It will be filed (and reviewed, where necessary) by the ECB s Medical Adviser, who will provide the Directorate General Human Resources with the following notificati for its files, stating that: On the basis of either my persal examinati or the medical data submitted to me for review, there are no medical grounds against the appointment of: Mr/ Ms/ NAME / MAIDEN NAME / First NAMES / DATE OF BIRTH) to the positi designated. All expenses should be paid directly by the applicant. The costs incurred will be reimbursed b y the ECB presentati of the appropriate receipts. Please send these to the attenti of HR Operatis.
2 Medical Examiner's Report (to be filled in by applicant) NAME: MAIDEN NAME:... FIRST NAMES: SEX:... DATE & PLACE OF BIRTH:... NATIONALITY:... MARITAL STATUS: unmarried married widowed divorced separated P ROFESSION:... APPOINTMENT AS:... I. Informati supplied by the candidate (to be filled in by the applicant) 1. (a) Has any member of your family (parents, brother/sister, spouse, child) ever had tubercu1osis? (b) (c) Has any member of your family (parents, brother/sister, spouse, child) ever suffered from mental ill health? What is the current state of health of your parents and brothers/sisters? 2. What illnesses and injuries, cases of hospitalisati, operatis, treatments at a spa or X-rays have you had in the past? 3. Do you have any disability? (a) Acknowledged permanent disability entitling you to a pensi: degree of invalidity: %, as certified by (b) Other disabilities: degree of invalidity:%, as certified by
3 4. Have an y of the illnesses, injuries, disabilities, etc. given under items 2 and 3 above ever resulted in your being unfit for duty over a lengthy period? If so, when and for how lg? 5. Are you suffering from any disorder or illness at the moment? Doctor treating the disorder or illness: 6. Specific questi if relevant for you: Are your periods irregular? Have you suffered from any pregnancy-related disorders? 7. Further informati: DECLARATION I, the undersigned, certify that the informati supplied above is true and correct to the best of my knowledge. I am aware of the fact that any omissis or any incorrect statements I might make could lead to the cancellati of my entitlement to certain allowances under the Cditis of Employment or of any appointment offered to me by the European Central Bank. Date:... Signature:... Please place this form in a separate sealed envelope addressed to the Medical Adviser of the ECB and return it to: European Central Bank Directorate General Human Resources ECB 's Medical Adviser c/o Medical Centre Snemannstrasse 20 D Frankfurt am Main
4 II. Results of the medical examinati undertaken.. Height (without shoes):... cm Weight (half-clothed):... kg 1. Physique Nutritial state Complexi Mucous membranes Musculature powerful, medium, weak* good, obese, medium, thin, undernourished* healthy, reddened, pale, yellowish, bluish-red* healthy, reddened, anaemic, bluish-red* compact, strg, medium, slack, thin* 2. Sensory organs Eyes, ears, nose, Normal colour visi 3. Oral cavity Dentiti, pharynx, tsils, thyroid, mandible glands 4. Respiratory organs Lung borders, pulmary percussi note, respiratory sounds, forced expirati 5. Circulatory system Heart boundary, heart tes, apex beat, pulse, blood pressure, heart functi test 6. Abdominal organs Abdominal walls, liver, spleen, renal bed, hernias, scars 7. Limbs Varicose veins, articulati 8. Nervous system Pupils, reflexes Psychological state 9. Blood tests: Haemogram: neutrophils eosinophils basophils lymphocytes mocytes thrombocytes Sedimentati rate: first hour secd hour Chemical analysis: creatinine urea glycemia uric acid total. cholesterol triglycerides
5 serum state gamma glutamyl transpeptidase (G.G.T.) 10. Urine tests: glucose protein blood ketes nitrites 11. Miscellaneous ECG, X-rays (if necessary) 12. Are there any medical grounds against the appointment? What disorders or illnesses were ascertained that (a) preclude or (b) reduce his/her suitability for the appointment? * Underline whatever is applicable. PLACE & DATE:... STAMP & DOCTOR'S SIGNATURE:...
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PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
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ANDRES PEISAJOVICH MD 3820 MASTHEAD ST NE ALBUQUERQUE, NM PH: FAX:
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Cy-Fair Hearing Aids Case History Form. Brandy R Jacobson Au.D. PERSONAL INFORMATION. Patient Name: Appointment Date: Date of Birth: Age: Gender: Male
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Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
An Outpatient Department of PLEASE FILL OUT ALL INFORMATION COMPLETELY Date Completed Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
3. PROCEDURE FOR MEDICAL EXAMINATION:
GUIDELINES AND CRITERIA FOR PHYSICAL FITNESS FOR PRE-EMPLOYMENT MEDICAL EXAMINATION 1. AIM: 1.1 The aim of these guidelines is to select, for a particular post, a person who must be in good physical and
Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:
PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: _( ) Marital Status: Married Single Divorced Widowed Cell Phone: