Formulrio Mdico

Membership no

(If known)

PARTE A - Para ser preenchido pela candidata e revisado pelo Mdico

Por favor observe que reter ou falsificar informaes pode resultar na remoo da candidata do programa.
NOME DA CANDIDATA - COMO APARECE NO PASSAPORTE
Sobrenome

Nome

Iniciais

Endereo Completo_____________________________________________________________________________________

CEP_________________________________Pas__________________Telefone___________________________________
Data de Nascimento (dd/mm/aaaa) ___________ Idade ______exo: Fem. ( ) Masc. ( )
Altura:_______________________________Peso____________________________________________________________
Contato mais prximo - por favor, fornea detalhes do parente ou pessoa que poderemos contatar em caso de emergncia
quando voc estiver nos EUA.
Nome___________________________________________Grau de parestesco com a candidata________________________
Endereo completo_____________________________________________________________________________________
____________________________________________________________________________________________________
CEP_______________________________Pas______________________________________________________________
Telefone (dia)__________________________________(noite)__________________________________________________
Voc tem um seguro adicional alm do providenciado pelo programa Au Pair in America?

Sim ( )

No( )

Se sim, fornea detalhes abaixo e anexe cpia dos documentos (escreva seu nome legvel em cada pgina)
____________________________________________________________________________________________________
Assinale se voc tem ou j teve:
( ) Tuberculose
( ) Catapora

( ) Malria

( ) Gravidez/Aborto

( ) Anemia
( ) Problema
Olhos
( ) Artrite

( ) Diabetes
( ) Herpes

( ) Doena Corao
( ) Problema Menstrual

( ) Infecco Ouvido
( ) Rubola

( ) Mononucleose
Infecciosa
( ) Doena Rim
( ) Sonambulismo

( ) Escarlatina

( ) Febre Reumtica

( ) Ulcera
( ) Vertigem/
Desmaio
( ) Doena Venrea

( ) Depresso
( ) Polio

( ) Epilepsia/Convulso
( ) Caxumba

( ) Problema viscula
biliar
( ) Bulimia
( ) Varizes

( ) Dores de
Cabea/Enxaquecas
( ) Anorexia
Hepatite A) ( ) B( ) C( )

( ) Hernia

( ) Asma

( ) Tentativa de
Suicdio

( ) Outras
Se voc assinalou algo acima, fornea detalhes incluindo data equivalentes_________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Quando foi a ltima vez que voc foi ao mdico e porqu? _____________________________________________________

Voc j recebeu aconselhamento ou medicao para condio nervosa, desarranjo alimentar, depresso ou problema
emocional? Sim ( ) No ( ) Se sim, fornea detalhes e datas_________________________________________________
____________________________________________________________________________________________________
Voc j foi vtima de abuso sexual, emocional ou fsico? Sim ( ) No ( ) Se sim, fornea detalhes e datas_____________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
H algum histrico familiar de fundo nervoso ou emocional, depresso ou abuso ( sexual, emocional ou fsico) ?
Sim ( ) No ( ) Se sim, fornea datas e detalhes__________________________________________________________
____________________________________________________________________________________________________
Assinale se voc sofre de alguma alergia:
( ) Penicilina ( ) Outras drogas ( ) Picadas de inseto ( ) Renite Alrgica ( ) Gneros Alimentcios ( ) Outros
Se voc marcou alguma das alternativas acima, d maiores detalhes:______________________________________________
____________________________________________________________________________________________________
Voc tem alguma habilidade fsica restrita? Sim ( ) No ( )
Voc tem algum hbito que possa prejudicar sua sade? (alcool, cigarros, drogas) Sim ( ) No ( )
Voc tem alguma doena crnica?

Sim ( ) No ( )

Voc toma alguma medicao frequentemente? (incluindo anticoncepcional) Sim ( ) No ( )

Voc sofre de alguma doena infecciosa como Hepatite B ou vrus HIV no sangue? Sim ( ) No ( )
Se voc assinalou algo acima, fornea detalhes completos, incluindo nomes da medicao______________________
______________________________________________________________________________________________
REABILITAO DE CRIMINOSOS decreto 1974 (excesses) Norma 1975
Pela natureza do trabalho a que voc est se candidatando, este programa est isento da Seo 4 (sub-seo 2/3) do Decreto
de 1974 de Reabilitao de Criminosos, e voc por essa razo no est autorizado a reter informaes sobre condenaes que
por outros propsitos esto abaixo do previsto pelo Decreto, e, na ocorrncia da participao, qualquer falha pode revelar suas
condenaes e poderia resultar no trmino do contrato.
Voc j foi acusada ou condenada de algum crime? Sim ( ) No ( )
Se sim, fornea detalhes completos__________________________________________________________________
______________________________________________________________________________________________
Eu compreendo e concordo que famlias americanas podem ter acesso a este Formulrio Mdico e dou permisso para que o
mdico que completou a Parte B deste formulrio reveja todas as respostas dadas por mim na Parte A e tambm para que
questione e providencie qualquer informao mdica adicional que seja necessria, caso a famlia americana solicite.
Caso ocorra uma situao de emergncia, eu autorizo qualquer rgo mdico a divulgar qualquer informao sobre minhas
condies mdicas para a Au Pair in Amrica, ou para o seguro mdico/servio de emergncia da mesma e compreendo que a
Au Pair in Amrica poder contactar o meu parente mais prximo sem meu prvio consentimento.
As informaes acima so verdadeiras e eu, por meio desta, dou permisso para cuidado mdico emergencial se for
necessrio.. Eu entendo que reter ou falsificar informaes pode resultar em minha remoo do programa.

Assinatura da Au Pair________________________________________________Data_________________________
Esse formulrio deve ser completado e assinado pela candidata.Lembre-se de fazer e levar uma cpia com voc para
os Estados Unidos.

Membership no
(If known)
NOME DA CANDIDATA - COMO APARECE NO PASSAPORTE
Sobrenome
PART B - Para ser preenchido pelo Mdico

Nome

Iniciais

Voc parente da candidata? No ( ) Por favor, parentes no podem preencher esse documento.
Como uma Au Pair in America, a candidata estar morando por um extenso perodo de tempo na casa de uma
famlia com filhos pequenos. Por essa razo, importante ns sermos avisados de qualquer problema de sade
emocional, mental ou fsico ou problema familiar que possa incapacitar a candidata de cumprir com suas
obrigaes apropriadamente. Por favor, observe que reter ou falsificar qualquer informao pode resultar no
afastamento da candidata do programa.
Por favor, examine as informaes da PARTE A e d sua opinio sobre o estado geral de sade da candidata.
Excelente ( )
Bom ( )
Satisfatrio ( )
Fraco ( )
Por favor, assegure se a candidata est imunisada contra os seguintes males:
Ttano
Sim ( ) Data ____________________ Sarampo

Sim ( ) Data_______ _________

Caxumba

Sim ( ) Data__________ ______

Sim ( ) Data ____________________

A candidata j foi imunizada contra tuberculose (TB) ?

Rubola

Sim ( ) No ( ) Data_____________

Caso a resposta seja negativa d detalhes do test ou anexe o mais recente resultado do raio-x do trax.
Teste de Tuberculose Data____________________
Resultado Negativo ( ) Positivo ( )
Por favor assegure tambm se a candidata est imunisada contra os seguintes males:
Febre Tifide

Sim ( ) No ( ) Data_____________ Difteria

Poliomelite

Sim ( ) No ( ) Data_____________ Tosse Comprida

Sim ( ) No ( ) Data_______________
Sim ( ) No ( ) Data______________

Marque X se houver alguma anormalidade nos seguintes sistemas:

Ouvido,Nariz e Garganta ( ) Olhos

( ) Neuropsiquitrico

( ) Crebro/Sistema Nervoso ( )

Pele

( ) Cardiovascular

( ) Ossos e Msculos

( ) Geniturinrio

Metabolismo

( ) Outros

( ) Sistema Respiratrio/Pulmes ( ) Gastrointestinal

( )
( )

Se voc assinalou algum dos itens acima, fornea detalhes e datas______________________________________________

___________________________________________________________________________________________________
___________________________________________________________________________________________________
A candidata, pelo seu conhecimento, uma provvel portadora de doena infecciosa, como Hepatite B ou C, ou vrus
HIV? (a candidata no precisa ser testada) Sim ( ) No ( ) Se sim, fornea detalhes________________________
___________________________________________________________________________________________________
Voc notou alguma mudana no peso ou hbitos alimentares da candidata que possa estar relacionado a doena de fundo
alimentar? Sim ( ) No ( ) Se sim, d detalhes e datas___________________________________________________
___________________________________________________________________________________________________
A candidata tem sido tratada/ aconselhada ou recebeu medicao para problemas nervosos, problemas alimentares,
depresso ou problemas emocionais? Sim ( ) No ( ) Se sim, d datas e detalhes e comente o estado emocional
presente da candidata_____________________________________________________________________________
A candidata j foi hospitalizada por mais de trs dias? Sim ( ) No ( ) Se sim, d detalhes e datas ________________

__________________________________________________________________________________________________
Voc tem conhecimento se a candidata j foi vtima de abuso fsico, emocional ou sexual) Sim ( ) No ( ) Se sim, por
favor comente ______________________________________________________________________________________

___________________________________________________________________________________________________
A candidata tem algum histrico de problemas emocionais, fsicos ou sexuais que voc deseja que a famlia
americana saiba para decidir se a candidata uma pessoa apropriada para viver em sua casa e cuidar de seus filhos
pequenos por um ano? Sim ( ) No ( ) Se sim, por favor comente__________________________________________
__________________________________________________________________________________________________
H algum histrico familiar da candidata de fundo nervoso ou problema emocional, depresso ou abuso (sexual,
emocional ou fsico) ? Sim ( ) No ( ) Se sim, fornea detalhes e datas______________________________________
___________________________________________________________________________________________________
A candidata, pelo seu conhecimento, j foi acusada ou condenada por algum crime? Sim ( ) No ( )
Se sim, fornea detalhes completos______________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Voc tem acesso a todos os pronturios mdicos da candidata? Sim ( ) No ( )
H quanto tempo voc conhece a candidata? _______________________________________________________________
Por favor, use esse espao para fornecer qualquer informao relevante adicional__________________________________

___________________________________________________________________________________________________
___________________________________________________________________________________________________
Nome do Mdico_____________________________________________________________________________________
Endereo___________________________________________________________________________________________
Telefone____________________________________________________________________________________________
Eu examinei ___ e/ou revisei as observaes mdicas ___ (marque a(s) alternativas corretas) da candidata e eu
asseguro que ela capaz de se beneficiar de uma participao completa do Programa Au Pair in America.
Voc fala Ingls? Sim ( ) No ( ) Se no, voc entendeu todas as questes desse formulrio? Sim ( ) No ( )

Assinatura___________________________________________________ Data______________________________

Por favor, coloque seu carimbo.

Medical Form

Membership no

If known

INSTRUCTIONS
PART A To be completed by Applicant and reviewed by Doctor
PART B To be completed by Doctor
3 Post or fax the other copy to the London office

1 Please complete this form immediately.

2 Make a copy of your completed form.

immediately or give it to your interviewer to forward.

4 Please note the Doctor completing this form may not

Keep one copy (original or photocopy) to take with you to the

United States.

be a family member.

PART A to be completed by Applicant & reviewed by Doctor

Please note that withholding or falsifying any information may result in the applicant being withdrawn from the program

NAME OF APPLICANT AS IT APPEARS IN PASSPORT

Last Name

First Name

Other Initials

Full Postal Address

Postcode

Country

Date of birth

Home Telephone No
Age

day

month

Height: feet/inches

Sex

Female

Male

year
or metres

Weight: pounds

or kilos

Next of kin please give details of the relative or person we can contact in case of an emergency when you are in the US
Name

Relationship to Applicant

Full Postal Address

Postcode
Telephone No (day)

Country

(evening)

Are you covered by additional insurance beyond that provided by the Au Pair in America program?

Yes

No

If yes, give details and attach a photocopy of the policy documents (write your name clearly on each page)

Tick the appropriate box if you presently suffer from or have ever had:
Pregnancy/Miscarriage
or Termination

Glandular fever

Heart disease

Ear infection

Kidney disease
Sleep walking

Anorexia

Tuberculosis

Chicken pox

Malaria

Anaemia

Diabetes

Eye problems

Herpes (cold sores)

Menstrual problems

Arthritis

Scarlet fever

Rheumatic fever

German measles
(rubella)
Gall bladder problems

Ulcers

Depression

Epilepsy/Convulsions

Bulimia

Dizziness/Fainting

Polio

Mumps

Varicose veins

Venereal disease

Hernia

Asthma

Suicide attempt

Migraines/Headaches

Hepatitis

Other (please specify)

If you have ticked any of the above, give details including dates as applicable

37 Queens Gate London SW7 5HR UK Tel: +44 (0)20 7581 7322 Fax: +44 (0)20 7581 7345
1

Membership no

Medical Form

If known

NAME OF APPLICANT AS IT APPEARS IN PASSPORT

Last Name

First Name

Other Initials

Other than to complete this medical form, when was the last time you visited a Doctor and why?

Have you ever received counseling and/or medication for a nervous condition, eating disorder, depression or emotional problem?
Yes

No

If yes, give details and dates

Have you ever been a victim of sexual, emotional or physical abuse?

Yes

No

If yes, give details and dates

Is there any history of nervous or emotional problems, depression or abuse (sexual, emotional or physical) in your family background?
Yes

No

If yes, give details and dates

Tick the appropriate box if you suffer from any allergies:

Penicillin

Other drugs

Insect sting

Hay fever

Foodstuffs

Other

If you have ticked any of the above, give full details

Is your physical ability restricted in any way?

Yes

No

Do you have any habits which may affect

your health (e.g. alcohol, cigarettes, drugs)?

Yes

No

Do you have any chronic or recurring illnesses?

Yes

No

Are you currently taking any medication?

(including oral contraceptives)

Yes

No

Do you carry any infectious diseases such as

Hepatitis B or the HIV virus in your blood?

Yes

No

If you have ticked any of the above, give full details including names of any medication

In view of the nature of the program for which you have applied, it is the practice of Au Pair in America and EduCare in America to request a
criminal record check.
Have you ever been convicted of a criminal offence, or are you at present the subject of criminal charges?

Yes

No

If yes, give full details

I understand and agree that American host families may have access to this Medical Form and give permission to the Doctor completing Part B to
review all my responses in Part A of this form and to provide or discuss additional medical information, if requested to do so by Au Pair in America.
Should an emergency situation arise, I authorize any medical provider to release information regarding my condition to Au Pair in America or their
insurance provider/emergency assistance services and understand that they can contact my next of kin without my prior consent.
The above information is correct to the best of my knowledge and I hereby give permission for emergency medical care to take place should it
be necessary. I also understand that withholding or falsifying any information may result in me being withdrawn from the program.

Signature

Date

Note: This form must be completed and signed by the applicant. Remember to keep a copy of your fully completed medical form and take it with you to the US.

Membership no

Medical Form

If known

NAME OF APPLICANT AS IT APPEARS IN PASSPORT

Last Name

First Name

Other Initials

PART B to be completed by Doctor

Are you related to the applicant?

Yes

No

Please note relatives may not complete this form.

As an au pair or companion in America, the applicant will be living for an extended period of time in the home of a family with young children.
It is therefore important that we are advised of any physical, mental or emotional health problems or family history issues which may have
a bearing on the applicants ability to carry out his/her duties appropriately. Please note that withholding or falsifying any information may
result in the applicant being withdrawn from the program.
Please review the information provided in PART A and give your opinion of the applicants general state of health:
Excellent

Good

Fair

Poor

Please ensure that the applicant is currently immunized/tested against the following:
Tetanus

Yes

Date

Measles

Yes

Date

Mumps

Yes

Date

German measles (rubella)

Yes

Date

Has the applicant been immunized against tuberculosis (TB)?

Yes

No

Immunization Date

If no, please provide details of a tuberculin test or attach the results of a recent chest x-ray. Test date

Result:

Negative
Positive

(Please note: positive test results will require additional information on dates the applicant had TB, details of any treatment and a copy of a recent chest x-ray.)

Please also indicate whether the applicant has been immunized against the following:
Typhoid

Yes

No

Date

Diphtheria

Yes

No

Date

Polio

Yes

No

Date

Whooping cough

Yes

No

Date

Tick the appropriate box if there are any abnormalities to the following systems:
Ears, nose and throat

Eyes

Neuropsychiatric

Respiratory system/lungs

Genitourinary

Skin

Cardiovascular

Musculoskeletal

Brain, nervous system

Gastrointestinal

Metabolic

Other

If you have ticked any of the above, please give details and dates

Is the applicant, to the best of your knowledge, a likely carrier of any infectious disease, such as Hepatitis B or C, or the HIV virus?
(The applicant does not need to be tested.)

Yes

No

If yes, give details

Have you noticed any changes in weight or eating habits for the applicant that may give rise to concern regarding an eating disorder?
Yes

No

If yes, give details and dates

Is the applicant currently or has the applicant ever been treated/counseled or received medication for a nervous condition, eating disorder,
depression or emotional problem?

Yes

No

If yes, give details and dates and comment on the applicants present emotional well being

Medical Form

Membership no

If known

NAME OF APPLICANT AS IT APPEARS IN PASSPORT

Last Name

First Name

Has the applicant been hospitalized for more than three days?

Yes

Other Initials
No

If yes, give details and dates

Have you any knowledge that the applicant has ever been a victim of physical, emotional or sexual abuse?

Yes

No

If yes, please comment

Does the applicant have any history of physical, emotional or sexually related problems that you might wish an American family to know as
they consider whether the applicant is a suitable person to live in their home and care for their small children for a year?

Yes

If yes, please comment

Is there any history of nervous or emotional problems, depression or abuse (sexual, emotional or physical) in the applicants family
background?

Yes

No

If yes, please give details and dates

Has the applicant, to the best of your knowledge, ever had any criminal convictions or charges filed against them?

Yes

No

If yes, please give full details

Do you have access to the patients full medical history?

Yes

No

How long have you known the applicant?

Please use this space to give any additional relevant information

Name of Doctor
Address

Telephone No
I have examined
and/or reviewed medical notes of
(tick as applicable) the
above named applicant and I find him/her to be capable of benefitting from and fully
participating in an Au Pair in America program.
Do you speak English?

Signature
4

Yes

No

Please add your Doctors or medical practice stamp here.

If no, did you fully understand all the questions asked on the form?

Date

Yes

No

No