CONFIDENTIAL

IOM MINIMUM MEDICAL REVIEW

QUESTIONNAIRE

Explanatory note:

The purpose of this questionnaire is to evaluate the current health status in conjunction with the availability
of health care services in their proposed duty station. The IOM Medical Officer of the Occupational Health
Unit (OHU) determines whether any further investigations or information is deemed to be necessary.

Please electronically complete and return this questionnaire as soon as possible (preferably within 3 days)
byemail to the IOM Medical Officer of the applicable unitof the Occupational Health Unit (OHU) in:

 PANAMA: for staffin Africa or in the Americas

 Switzerland -GENEVA: for staff in Headquarters
 Philippines -MANILA: for staff in all other locations

IOM: Chief Medical Officer

IOM:Medical Officer OHU IOM:Medical Officer OHU
OHU Occupational Health Unit
P.O. Box 0819-0017 Manila Administrative Center
17 route des Morillons
El Dorado 25th Floor Tower 6789
CP 17
Panamá 6789 Ayala Avenue, Makati City
1211 Geneva 19
República de Panamá Philippines 1209
Switzerland
Tel. No.: +507 305 33 50 Tel. No.: + 632 848 0561
Tel. No.: + 41 22 717 93 54
Fax No.: +507 305 33 51 Fax No.: + 632 848 14 39
Fax No.: + 41 22 717 94 10
E-mail: OHUPAC@iom.int E-mail: OHUMAC@iom.int
E-mail: OHUGVA@iom.int

PERN: Job title:

Family Name (in block capitals): HARUN Duty station: IOM Cotabato Sub Office

Given names:AL-WAHAB

Date of birth (D/M/Y): 08/08/1982 Gender:Female __Male __Other*__

*difference of sexual development (DSD, intersex)

Nationality: Filipino Home address: Cagayan De Oro City

E-mail: Telephone numbers (incl. country code): none

OHU_MMRQ_2019 (EN)

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Name, full address, telephone number and email of your doctor:

 Family doctor: None

 Specialist health professional if any (indicate the type of specialty) None

1. Have you been admitted to the hospital for at least 2 consecutive days in the last 5 years, or have you been absent from
work for more than 30 days in the last 12 months?

Yes____ No____If “yes please indicate the medical reason / diagnosis

2. Are you regularly taking any prescribed medication? Do you have any allergies to medication?

Yes____ No____If “yes” please provide details(please include name/or generic name of medication, dose and frequency)

3. Do you have any condition which will need medical, surgical or psychological intervention or treatment within the next
12 months or an ongoing treatment?

Yes____ No____If “yes please provide detail

4. Are you currently pregnant?

Yes____ No____ If “yes” please state the expected date of delivery (D/M/Y):

5. Do you have any physical or mental health conditions which could make it difficult for you to live and work in, or travel
to, a remote area with limited access to health care facilities?

Yes____ No____If “yes” please provide details and medical certificate

6. Have you ever suffered from a physical or psychological condition which has been recognized as caused by previous
work or internship?

Yes____ No____If “yes please provide details

7. Do you, or will you need any workplace accommodations for medical conditions, and/or disability? (For example do you
have travel limitations, or need a special desk, etc.)

Yes____ No____If “yes please provide details

8. Are you aware of any other factors which could affect your health or your ability to perform your duties (such as
physical symptoms, lifestyle habits or family circumstances)

OHU_MMRQ_2019 (EN)

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Yes____ No____If “yes please provide details

9. Have you had any of the following symptoms in the past 6 months? None

Underline the symptoms concerned and give details: Coughing or spitting blood, breathing difficulties, blood in your stools, blood
in your urine, chest pain, breathing difficulties, abdominal pain, back pain, fainting, loss of consciousness, seizure, depression,
panic attacks, vertigo, involuntary loss of weight (over3kg), heartpalpitations,unexplained chronic fatigue, transient palsy or loss
of vision.

Please provide a copy of your full vaccination record: None

Declaration - Please read, sign and either check ACCEPT or DECLINE the declaration

I hereby declare that my answers to all questions are true and complete to the best of my knowledge. I also hereby authorize the
reviewing Medical Officer to communicate with my treating physician, or mental health professional, and I simultaneously give
consent to my treating practitioner(s) to release the necessary medical information in order to verify my state of health in relation
to fitness for work.

I understand that failure to disclose a known physical and psychological condition, including conditions under investigation, may
result in future denial of benefits, termination or dismissal.

You must check one box:I ACCEPT ____ I DECLINE ____

Date: December 11, 2020 Staff’s signature:

For administrative internal use only:

Date:

Fitness classification 1A____ 1B____ 2 ____

Further information neededor referral to SW advised:

Medical conditions upon entry:

 Illness:

 Accident:

 Allergy:

Date: OHU Medical Officer’s signature:

OHU_MMRQ_2019 (EN)