TO WHOM IT MAY CONCERN
PERSONAL DETAILSName:
ID / Passport Number:
Nationality:
Phone Number:
Date of Birth:
Gender:
Email address:
Home country:
Position:
Destination:
REVIEW OF SYSTEMS
| Do you have any of the following? | |||
|---|---|---|---|
| Fevers | Loss of memory | ||
| Headaches | Chest Pain or tightness | ||
| Difficulty with vision / Wear lenses or glasses | Abdominal pain | ||
| Dizziness / Vertigo | Kidney Stones | ||
| Tiredness or falling asleep during the day | Back pain | ||
| Unable to tolerate heat or cold | Joint pain or swelling | ||
| Shortness of breath with or without exertion | History of broken bones | ||
| Sneezing | Swelling of the legs | ||
| Cough | Skin problems (rash, eczema, psoriasis) | ||
| Allergies | High Blood Pressure | ||
| Carpal Tunnel Syndrome | Diabetes |
Do you smoke?
If yes, what do you smoke and how many per day?
Do you drink alcohol?
If yes, what do you drink and how much?
Vaccination
⮱
Current medical condition (if any, list those that you are currently receiving treatment for. Date, month and year)
⮱
Do you have allergies to any medications or other substances? If yes, please specify.
⮱
Please list prescribed medications and over the counter medications that you take.
⮱
Are you currently under the treatment or care of a physician or other health care provider?
⮱
Do you have any condition (physical, medical, or psychological) that would require special accommodations in order for you to preform your job? If yes, please specify.
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PHYSICAL EXAMINATION
Height
Weight
Vision
Right Eye:
Left Eye:
Both Eyes:
Neck
Chest/Lungs
Heart
Abdomen
Musculoskeletal
Neurological
Skin
Other
Applicant's Clearance
✓ I, as an applicant, authorize the release to the issuer of all information contained on this examination form and all other forms generated as a direct result of my examination.
✓ I hereby understand that, due to the nature of this examination (ONLINE EXAMINATION), I take full responsibility for the above information.
✓ I hereby agree and confirm that all my personal information and data stated above are accurate. I understand that false, inaccurate, or missing information will invalidate this certificate. I hereby consent and authorise to process any of my datas (including any personal sensitive data) and / or to release my physical examination certificate.
Name of Applicant
Signature of Applicant
Examination Method:
Online Examination
Examination Time:
30 Minutes
Due to the nature of this examination (ONLINE EXAMINATION) and the obligation to respect his / her privacy, we cannot take any responsibility for the above information. Using the above information, we find him / her:
✓ Medically fit
Not medically fit
Date of Examination
Issuer
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