Serial No

Last Name : ………………………….

Height : ………….Ft………..In……….

Sex : ……………………………………

Age : ………..

Passport No : ………………………

Position applied for : ……………………

History of any significant post illness including:

1.) Psychotic and neurological disorders

     (Epilepsy. depression. Schizophrenia……

 2.) Allergy         3.) Others

First Name :……………….

Wt …….    Lbs ………

Status : ……………..

Nationality : …………

Place of issue : ………..

Recruiting Agency…………………….

I hereby permit the………………..and the undersigned physician to furnish such information the company pertaining to my health status and other pertinent and medical findings and do hereby release them from any and all legal from my employment benefits and claims.

                                                         Signature of Examinee  ……………………….                                                  

TYPE OF MEDICAL EXAMINATIONS

RESULTS

                                         Rt

EYE …………. ……….

                                        Lt

                                        Rt

EAR …………………..

                                        Lt

SYSTEM EXAM

       CARDIO-VASCULAR

       B.P………………

       HEART…………….

RESPIRATORY SYSTEM

      LUNGS……………

      CHEST X-RAY

GASTRO INTESTINAL

          ABDONEN

  OTHERS

HERNIA

VARICOSE VEINS

EXTRENITIES

DEFORMITIES

SKIN

VENEREAL DISESES

          CLINICAL

C N S

PSYCHIATRY

TYPE OF AB INVISTIGATONS

RESULTS

URINE

             SUGAR                          

             ALBUMIN

             BILHARZIASIS

            (IF ENDEMIC)

STOOL

            ROUTINE

1.        HELMINTHES

2.        GUARDIA

3.        BILHZIASIS (IF ENDAIC CULTURE)

4.        SALMONELLA

       SHEGLLLA

                V CHOLERA (IF ENDEMIC)

BLOOD

               HAEMOGLORIS

               THICNFILM FOR

1.        MALARIA

2.        MICRO FILARIA

SEROLOGY

1.        F B S

2.        L E T S

3.        CREATINNE

EMSA

1.        HIV 1.2 TEST

2.        HBs Ag

3.        Anti HCV

VDRL

  TPHA  (IF VDRL POSITIVE)

PREGNANCY TEST