Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
2. Are you currently seeing your GP regularly for any reason, or attending a
hospital
outpatient, or on a hospital waiting list?
No
If yes, please give details:
Yes
Yes
Yes
5. Do you smoke
tobacco?
Yes No
Yes No
Yes/No
Details:
Yes/No
Details:
Yes/No
Details:
Yes
Yes
disorder
breast cancer depression/anxiety/psychosis alcohol or drug dependency
other
If yes, please give details:
note the
Use the space below to give further about dates, severity, treatment, duration, results of any investigations
and medication prescribed
Yes/No
Appr
ox
date
Did you
see your
GP?
Yes/No
Yes/N
o
Appr
ox
Did you
see your
date
GP?
Yes/No
Yes/No
Summary: Is there any other medical information you would like to give
which you have not included already?
..
..
..
Please document any particular concerns you may have related to your
health while a volunteer overseas. Please discuss these with the
doctor during your medical examination, or contact International
Service.
..
..
..
Declaration
Please read these statements carefully before signing:
I hereby declare that all the foregoing answers are true and, to the best of my
knowledge, I have not withheld any information. I understand that failure to
disclose any existing or previous medical condition may invalidate my medical
insurance whilst overseas.
I give permission for the contents of this form to be forwarded to International
Services current insurers if this is necessary for my insurance cover.
I give permission for the International Service (UK) Medical Adviser to contact my
doctor for further medical information should this be required.
Signed:
Date:
CONFIDENTIAL
Given names
Sex
Age
Date of examination
Condition
Treatment required
Cured
yes/no?
Tick if
normal
General health
Allergy history
Eyes
Ear, nose & throat
Dental condition
Respiratory
Cardiovascular
Urinary
Gastro-intestinal
Reproductive health
and/or menstrual cycle
Locomotor
Skin
Central nervous
Other
Physical examination
Height
(ms)
Pulse
----------------
-------------Weight
(kgs)
Blood
pressure
---------------
------------------
Urinalysis:
Blood
..
Protein
.
Glucose
.
Further urine investigations if indicated:
Tick if
norma
l
General condition and
appearance
Eyes (pupils, fundi, visual
fields, ocular movement)
Ear, nose and throat
Lungs and chest
(include PEFR if asthmatic)
Cardiovascular system
Breast examination
(only if indicated)
Abdomen
(note if hernia present)
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Genito-urinary system
(vaginal or genital
examination only if
indicated)
Rectal examination only if
indicated
Skin
Back, joints and limbs
Central nervous system
(sensory, motor reflexes,
equilibrium)
Any additional comments about the candidate's physical status:
Condition
Treatment received
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Reaction to stress:
Please comment, as far as you can, on how you think this person would adapt to
the stresses of living and working in a developing country where medical facilities
may be limited, non-existent or difficult to access. Living conditions may be
challenging, their diet limited and climatic conditions harsh. Please take into
account any previous psychological problems and this person's historical reaction
to stress related problems.
Current medications
Please give details of current repeat prescriptions (including contraceptive pill and
asthma inhalers)
Name of medication
Frequency
Dose
1.
________________
___________
______________
2.
________________
___________
______________
3.
________________
___________
______________
4.
________________
___________
______________
5.
________________
___________
______________
NB: We would be most grateful if you could provide as large a supply as possible
for the volunteer to take with them overseas.
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Laboratory investigations
We do not routinely require any laboratory tests performed unless you feel they
are clinically indicated. However, if you have any results of recent investigations
for this person, which you think may contribute to an assessment of their current
health, please enclose details or document below.
Some volunteers will require specific tests and investigations for visa or work
permit reasons. Please note, we do not require the results of these tests for the
purposes of this medical examination form.
Final assessment
International Service ICS overseas placements are likely to be in rural areas or
smaller towns of poorly resourced countries, rather than in larger centres. Living
and working conditions may be physically challenging and at times stressful. Local
immediate medical assistance may be very limited.
Given your knowledge of this person, their medical history and the
findings of this examination:
If medically fit, would you make any specific recommendations for this
persons placement? Please give details:
Will this person require any routine follow up during their time overseas?
Please give details:
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Practice stamp:
Telephone number:
Fax number:
International Service, Rougier House, 5 Rougier House, York, YO1 6HZ
Tel: +44 (0)1904 647799
Fax: +44 (0)1904 652353
Please note
It is the volunteer's responsibility to ensure that the completed form is returned to
the Medical Unit as soon as possible, to enable us to process their medical
clearance without delay. We would therefore be grateful if you could hand the
completed form to him/her at the end of the examination.
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