Part 1 : Personal Information (This part is to be completed by the applicant)
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1 MEDICAL REPORT FOR FOREIGN WORKER FOR EMPLOYMENT IN BRUNEI DARUSSALAM (in accordance with The Infectious Diseases Order; Immigration Act and Labor Act of the Statutes of Brunei Darussalam) photo Accreditation no: Part 1 : Personal Information (This part is to be completed by the applicant) Ref. no.: 1. FULL NAME:... (please underline surname) 2. SEX: MALE / FEMALE 3. DATE OF BIRTH : 4. PASSPORT NO: 5. TYPE OF JOB APPLIED : 6. ADDRESS IN COUNTRY OF ORIGIN :.. 7. NAME OF EMPLOYER / RECRUITING AGENCY : FULL ADDRESS OF EMPLOYER / RECRUITING AGENCY:.. PART II : MEDICAL HISTORY (To be completed by the attending physician) Has the worker ever suffered from or experienced or received treatment for the following diseases and conditions? If YES, please indicate dates of detection and treatment received. 1 HIV / AIDS * 2 TUBERCULOSIS * 3 EPILEPSY * 4 LEPROSY* 5 SEXUALLY TRANSMITTED INFECTIONS * 6 PSYCHIATRIC ILLNESS * 7 HEPATITIS B* 8 DRUG USE * 9 DIABETES MELLITUS ** 10 HYPERTENSION ** 11 CANCER ** 12 BRONCHIAL ASTHMA ** 13 HEART DISEASE ** 14 KIDNEY DISEASE ** 15 HEARING PROBLEM** 16 VISION PROBLEM** 17 PEPTIC ULCER** 18 MALARIA 19 OTHERS (Please state) YES NO DATE/TREATMENT * To be considered unfit if answered yes to any of the item ** Fitness up to the discretion of the attending Physician; must indicate severity, complications and medications currently taken by the applicant
2 PART III : PHYSICAL EXAMINATION AND INVESTIGATIONS (To be completed by the attending physician ) Section A : General Physical Examination 1. Height : cm 2. Weight : kg 3. Pulse : /min 4. Blood pressure : mmhg (Systolic /Diastolic) 5 Chronic skin rash/sores on hands 6 Anaesthetic skin patch 7 Deformities of limbs 8 Anaemia 9 Jaundice 10 Lymph node enlargement 11 Hearing impairment PRESENT RIGHT ABSENT LEFT 12 Vision test Unaided Aided Colour blindness PRESENT ABSENT 1 Cardiovascular System 1.1. Heart Size 1.2. Heart Sounds 1.3. Other Findings 2 Respiratory System 2.1. Breath Sounds 2.2. Other Findings Section B : Systemic Examination 3 Gastrointestinal System 3.1. Liver 3.2. Spleen 3.3. Kidney 3.4. Is there any abnormal swelling? YES / NO Indicate if YES 3.5. Rectal Examination Normal Abnormal 4 Central Nervous System Normal Abnormal 4.1. General Mental Status 4.2. Speech 4.3. Cognitive Function 4.4. Motor power 4.5. Sensory 4.6. Reflexes 5 Genitourinary System YES NO 5.1. Discharge 5.2. Sores / Ulcers
3 Section C : Laboratory Results and X-ray Findings Negative Positive 1 Blood 1.1. HIV Antibody # 1.2. HbsAg # 1.3. VDRL /TPHA # 1.4. Malaria Parasite If positive for malaria, give appropriate treatment and then repeat 1.4 Date when blood test for malaria parasite is found negative after treatment : 2. Urine Examination 2.1. Urine Examination - Colour : Specific Gravity : Negative Positive Sugar Albumin Microscopic Examination : Others: 2.2. Opiates / Cannabis # 2.3. Pregnancy # 3 Chest X-Ray Report (Large film) (valid for 6 months- UNFIT IF ANY ABNORMALITY IN THE LUNG FIELDS are present) Normal Abnormal 4 Stool examination # [for those handling food] Negative Positive Salmonella Typhii V.Cholera V.Parahaemolyticus Shigella E.Histolytica Other enteropathogens (please state) If positive for any of the above, give appropriate treatment and then repeat stool exam Date when stool exam is found negative for all of the above after treatment : 5 Sputum AFB (if indicated) POSITIVE NEGATIVE 6 ECG (if indicated) NORMAL ABNORMAL 7 Slit skin smear (if indicated) POSITIVE NEGATIVE # To be considered unfit if found positive/ abnormal PART IV: VACCINATIONS GIVEN (IF APPLICABLE) Vaccine Batch no. Given by 1. Typhoid/Paratyphoid 2. Tetanus 3. Hepatitis B 4. Others (Please state)
4 PART V: CERTIFICATION BY PHYSICIAN I HAVE EXAMINED THE ABOVENAMED APPLICANT AND FOUND THAT HE / SHE IS FREE FROM THE FOLLOWING DISEASES: YES NO HIV / AIDS TUBERCULOSIS MALARIA LEPROSY SEXUALLY TRANSMITTED INFECTIONS HEPATITIS B EPILEPSY PSYCHIATRIC ILLNESS AND HIS / HER URINE IS FOUND NOT TO CONTAIN OPIATE / CANNABIS. SHE IS / IS NOT PREGNANT (IF APPLICABLE) HE / SHE HAS / HAS NOT BEEN GIVEN THE APPROPRIATE VACCINATIONS (IF APPLICABLE) HE / SHE IS FIT / UNFIT TO BE EMPLOYED IN THE JOB THAT HE / SHE IS APPLYING FOR I THEREFORE RECOMMEND THAT HE / SHE BE CONSIDERED / NOT CONSIDERED FOR EMPLOYMENT (IF NOT CONSIDERED FOR EMPLOYMENT PLEASE STATE THE REASON(S) BELOW) SIGNATURE DATE NAME OF CERTIFYING PHYSICIAN: ADDRESS OF PHYSICIAN: QUALIFICATIONS: OFFICIAL STAMP (TO BE RETAINED BY THE EXAMINING PHYSICIAN)
5 MINISTRY OF HEALTH BRUNEI DARUSSALAM MEDICAL CERTIFICATE FOR FOREIGN WORKER (Please attach all results of investigations, X-Ray and radiologist report) Accreditation no:. Ref.no: 1. FULL NAME:. (please underline surname) 2. SEX: MALE / FEMALE 3. DATE OF BIRTH :. 4. PASSPORT NO: 5. TYPE OF JOB APPLIED :.. 6. FULL ADDRESS IN COUNTRY OF ORIGIN :. 7. NAME AND FULL ADDRESS OF EMPLOYER / RECRUITING AGENCY.. I HAVE EXAMINED THE ABOVE NAMED APPLICANT AND FOUND THAT HE / SHE IS FREE FROM THE FOLLOWING DISEASES: HIV / AIDS TUBERCULOSIS MALARIA LEPROSY SEXUALLY TRANSMITTED INFECTIONS HEPATITIS B EPILEPSY PSYCHIATRIC ILLNESS AND HIS / HER URINE IS FOUND NOT TO CONTAIN OPIATE / CANNABIS SHE IS NOT PREGNANT (IF APPLICABLE) HE / SHE HAS BEEN GIVEN THE APPROPRIATE VACCINATIONS (PLEASE STATE IF GIVEN) HE / SHE IS FIT TO BE EMPLOYED IN THE JOB THAT HE / SHE IS APPLYING FOR I THEREFORE RECOMMEND THAT HE / SHE BE CONSIDERED FOR EMPLOYMENT SIGNATURE DATE NAME OF CERTIFYING PHYSICIAN: ADDRESS OF PHYSICIAN: QUALIFICATIONS: TEL.NO: FAX NO: Official stamp Photo (TO BE RETAINED BY THE WORKER) VALID ONLY FOR THREE MONTHS FROM THE DATE OF ISSUE
6 FOR OFFICIAL USE ONLY BY THE EMBASSY/HIGH COMMISSION/CONSULATE OR REPRESENTATIVE OFFICE OF BRUNEI DARUSSALAM Accreditation no:.. Ref.no: 1. FULL NAME:... (please underline surname) 2. SEX: MALE / FEMALE 3. DATE OF BIRTH :. 4. PASSPORT NO: 5. TYPE OF JOB APPLIED :. 6. ADDRESS IN COUNTRY OF ORIGIN :.. 7. NAME OF EMPLOYER / RECRUITING AGENCY :.. 8. FULL ADDRESS OF EMPLOYER / RECRUTING AGENCY :.. I HAVE PERUSED THE ABOVE APPLICANT S PRE-EMPLOYMENT MEDICAL DOCUMENTS AND FOUND THAT THE RECORDS ARE / ARE NOT IN ORDER AND HEREBY: - ISSUE - NOT ISSUE AN EMPLOYMENT ENTRY VISA. VISA NUMBER ISSUED: SIGNATURE DATE NAME OF OFFICIAL: DESIGNATION: APPLICANT S PHOTO OFFICIAL STAMP (TO BE RETAINED AT THE ABOVE OFFICE FOR FUTURE REFERENCE)
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LAWRENCE MEMORIAL/REGIS COLLEGE NURSING & RADIOGRAPHY PROGRAMS Student Health Record All three parts of this record must be complete. Health Records must be uploaded to the Castle Branch website at https://mycb.castlebranch.com
Patient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
Smoking history Alcohol history Never Quit Never Quit PART 2 - MEDICAL HISTORY Date of last colonoscopy? Date of last mammogram? Date of last pap smear? Date of last flu vaccine? Date of last pneumonia
Keiser University Health Forms. Student Name: D.O.B. / /
These forms must be returned to Sentry MD. DO NOT RETURN THESE FORMS TO KEISER UNIVERSITY. Please return forms to Sentry MD, by emailing them as ONE PDF ATTACHMENT to Keiser@SentryMD.com or fax to 817-251-9593
Penn State New Kensington Radiological Sciences Program Physical Examination
Penn State New Kensington Radiological Sciences Program Physical Examination Personal Information (Student information) First Name: Middle Name: Last Name: Sex: Date of Birth (mm/dd/yyyy): Address: City:
Personal Health Risk Appraisal
Today s Date: Premier Arthritis and Osteoporosis Center 722 North Fairfield Road Beavercreek, OH 45434 Phone (937) 208-7000 Fax (937) 208-7010 Personal Health Risk Appraisal Last Name: First Name: MI:
GEORGE WASHINGTON UNIVERSITY HOSPITAL EMPLOYEE HEALTH SERVICES REQUIREMENTS FOR CLEARANCE:
GEORGE WASHINGTON UNIVERSITY HOSPITAL EMPLOYEE HEALTH SERVICES Office: 202 715 4275 Fax: 202 715 4587 Email: gwuehs@medcor.com Walk-in hours: M-F 8am-12pm and 1pm-4pm REQUIREMENTS FOR CLEARANCE: Physical
Occupation Agency Code Work Location Work Supervisor Duty tel. #
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
OCCUPATIONAL HEALTH PROTOCOL
Faculty of Medicine and Surgery OCCUPATIONAL HEALTH PROTOCOL (Applicable to applicants for the Doctor of Medicine and Surgery M.D. - Degree Course) Applicability for Courses commencing in October 2015
Date: New Patient Form First Visit Date:
Date: New Patient Form First Visit Date: **PATIENT INFORMATION** **PRIMARY INSURANCE** Name: Insurance Company: Street: Claim Address: Facility/Complex City/state/Zip: Group #: Town/State/Zip: Policy/
THE OB/GYN CENTRE NEW PATIENT HISTORY
PERSONAL PROFILE NAME: AGE: NAME YOU WOULD LIKE US TO USE: OCCUPATION: MARITAL STATUS: GYNECOLOGICAL HISTORY LAST MENSTRUAL PERIOD (FIRST DAY): AGE PERIOD BEGAN: PRESENT BIRTH CONTROL PAST METHODS OF BIRTH
Aspire Pain Medical Center
Aspire Pain Medical Center Welcome to Aspire Pain Medical Center. We are looking forward to providing you with the best care to manage your needs. Please take the time to complete the following questionnaire
Home Number: ( ) Cell Number: ( ) SSN#: Address: Address: Date of Birth Sex. Place of Birth Marital Status: (Optional) (City & State)
I. APPLICATION INSTRUCTIONS: School of Ultrasound Telephone (225) 756-3327 APPLICATION FOR APPOINTMENT AS STUDENT ULTRASOUND TECHNOLOGIST IN CARDIAC AND VASCULAR Applications for Admissions must include
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
PATIENT INFORMATION. First
GUIDE DOGS OF AMERICA General Physician s Report This General Physician s Report is being requested in connection with an application for a guide dog. We require a recent physical exam and complete medical
OCCUPATIONAL HEALTH PROTOCOL
Faculty of Dental Surgery OCCUPATIONAL HEALTH PROTOCOL Applicable to applicants for the: Master of Dental Surgery Course Bachelor of Science (Honours) in Dental Hygiene Course Bachelor of Science (Honours)
Assessment of Fitness to Drive to be completed by medical practitioner
COMMERCIAL VEHICLE DRIVER MEDICAL ASSESSMENT This Medical Assessment meets the requirements of the following Western Australian Government Authorities; Department of Commerce, WorkSafe - Occupational Safety