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MEDICAL REPORT FOR OTTAWA EMBASSY
NAME: ____________________________________
SEX:____ AGE: ______ STATUS: _________ NATIONALITY: ___________
PASSPORT #: _______________PLACE & DATE OF
ISSUE: ____________
POSITION APPLIED FOR: ___________________________________
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Dear Sir,
Please arrange to examine the above mentioned candidate
whether he/she is fit for the above mentioned position:
____________________________________
_______________________________________
DATE:
RECRUITMENT ATTACHE OR DOCTOR:
History of any significant past illness including:
1. Psychiatrist and neurological disorders (Epilepsy,
Depression...)
2. Allergy
___________________________________________________
__________________________________________________
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| MEDICAL EXAMINATION |
NEG |
POS |
LABORATORY INVESTIGATION |
NEG |
POS |
EYE *Vision
R eye
L eye
*Others
R eye
L eye |
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URINE
*Sugar
*Albumin
*Bilharziasis
*Others
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EAR
Right ear
Left ear |
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Mantoux TB Skin Test |
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SYSTEMIC EXAM
Blood Pressure
Heart
Lungs
Abdomen |
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STOOL (Ova & Parasite)
*Halminthes
*Salmonella /Shigella
*V. Cholera
*Others
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OTHERS
*Hernia
*Varicose veins
Extremities
Skin |
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BLOOD
*Hemoglobin
*Malaria film
*Others |
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VENEREAL DISEASES
*Clinical
*Lab VDRL
(RPR)
TPHA |
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SEROLOGY
*HIV test (3)
*F.B.S
*HBsAg/Anti H C V
*L.F.T.
*Creatinine
*Urea
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| CHEST X- RAY PA & Lateral |
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Women - PAP & Pregnancy |
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| Confirm if the
applicant has one of the following: |
Yes |
No |
Notes |
| Communicable diseases |
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| Mental disorder |
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| Physical disorders |
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| Handicap |
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| Paralysis |
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| Blindness |
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| Deafness |
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| Dumbness |
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Dear Sir:
This is the medical report for Mr.\Mrs.\Miss . ________________________________
He/she is [ ] FIT [
] UNFIT for the above mentioned job.
1. Stamp of the recruitment attache or Doctor on the
photo and the application.
2. Chest: Free of pathological changes.
3. HIV from a provincial laboratory.
4. To be fit, all medical examinations and laboratory
investigations should be within normal limits.
N.B. Present to the Consulate the original and one copy
of this report and the test results. The medical report and results of
the X-rays should be submitted to the health authorities in Saudi Arabia.
The Embassy is not financially responsible.
Physician Name: Signature: _____________________________________________
License number: Stamp (if available) _______________________________________
This form must be signed by [one] of the two following
authorities.
This is to verify that Dr. License no. Dept. Stamp
________________ is currently registered with the _____________________
and is authorized to practice medicine in ____________________________.
Location
__________________________ _______________________
Authorized signature Seal or Stamp of Prof. Lic. Authority.
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