MEDICAL EXAMINATION REPORT Name: ‘Student Number: Address: Contact No/s. Date of Birth: _/__/___ Age:__ Sex: 0M CIF Status: ___ Nationality: _ _ (PERINESINA(10 ve rec up by stucent) Any history of previous hospitalizations or surgical operations? ONO (YES Please Specify: __ Any history of accidents/injuries? CUNO DYES Pease Specify Any history of mental or psychological problem? NO OES Please Specify: Any history of allergies? (INO CYESPlease Specity; Any medical condition? CD.NO DYES Please Speaty: —_ Current medication: Immunizations: Hepatitis A: 01" 2" Hepatitis8: 01" O2" Varicella: = 1" 02" MMR. or a Tetanus Toxoid booster: (within the last 10 years) Others: I hereby certify that the above statements are true and correct to the best of my knowledge. ‘SIGNATURE OVER PNTED mA OF STUDENT NESTE (0 be “eo up oy attenaing physician) Weight: Height: ent Vital Signs: BP_CR_RR__Temp._ { Tormal | Abnormal | Comments [~~ Normal [Abnormal Comments [General 7 , k ‘Skin ~ _ T Head — = eyes t - (Fear/Nose/Throat { t [teeth & Gums I i [ek & Thyroid t | *Please use back of this page for ad PHYSICALLY FIT TO TRAVEL REMARKS: Attending Physicians’ Name: Titles Signature: _ Date Issued: Clinic Address: Contact Number: i 3 é : 7 i 3 3 q i i i , a § B 3 3 : i 8 if z 5 z