Medical Report for
Medical Report
Full Name: ______________________ Date of Birth: ___________________
Please answer ‘yes’ or ‘no’ to the following questions. If in doubt consult your doctor.
If answering ‘yes’ on any point give details below. Use a separate sheet if necessary.
1. Do you have recurring / ongoing problems in the following areas?
|Headaches | |Epilepsy / Fits | |
|Earaches | |Diabetes | |
|Sore Throats | |High Blood Pressure | |
|Sinus Trouble | |Fainting Episodes / Blackouts | |
|Toothache | |Back, Neck or Joint Problem | |
|Eye Strain | |Stomach Upsets | |
|Dyslexia | |Bladder Trouble | |
|Asthma | |Tenosynovitis / R.S.I. | |
|Hay Fever | |Depression/Nervous Illness/ | |
| | |Mental Disorder | |
|Skin Condition | |M.E. (Myalgic Encephalomyelitis) / | |
| | |Chronic Fatigue Syndrome | |
|Allergy | |Anorexia/Bulimia | |
|Sleeping Difficulty/Snoring | |
|Any condition not mentioned | |
2. Have you ever been diagnosed with any of the following?
|Asthma | |HIV | |
|Tuberculosis | |Epilepsy | |
|Malaria | |Tenosynovitis / R.S.I | |
|A.D.D. | |Depression/Nervous Illness/Mental Disorder| |
|(Attention Deficit Disorder) | | | |
|Hepatitis (A, B or C) | |Anorexia/Bulimia | |
| | |M.E. (Myalgic Encephalomyelitis) / | |
| | |Chronic Fatigue Syndrome | |
3. Have you had any other serious illnesses, operations, accidents or injuries?
4. If so, do you have any disability or physical limitation as a result?
5. Are you having any medical treatment (including medication) at present? If so, please specify.
6. Are there any foods or drinks you are not able to take?
Immunisation Checklist
| |Date Immunised |Booster Date | | |Date Immunised |Booster Date |
|Tetanus | | | |Hep B | | |
|Diptheria | | | |Hep A | | |
|Polio | | | |BCG | | |
Note: Up to date immunisations are required for Tetanus, Polio, and Hepatitis B.
I declare that, to the best of my knowledge, the given information is true and complete.
Signature of Applicant : __________________________ Date: _________________________
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