Certificat medical stages
|Direction de l’Energie Nucléaire |
|Unités de Gestion |
|Service du Personnel et des Affaires Sociales |
|Bureau de Gestion et des Affaires Sociales |
| |
| |
| |
| |
| |
MEDICAL FILE TO BE DULY COMPLETED BY YOUR DOCTOR OF MEDICINE
MEDICAL CERTIFICATE
|CANDIDATE’S FIRST AND LAST NAME: |Nationality: |
| | |
| | |
|FRENCH SOCIAL SECURITY N° (If applicable) |
|MEDICAL HISTORY: |
| |
| |
|MEDICAL HISTORY IN RELATION TO YOUR PROFESSION: |
| |
|HISTORY OF PROFESSIONAL AND/OR MEDICAL RADIATION EXPOSURE - DOSE RECORDED: |
| |
|EYESIGHT COLORS |NEAR |FAR |
|visual acuity |sc |cc |sc |cc |
|right eye | | | | |
|left eye | | | | |
|MUSCULOSKELETAL SYSTEM - SKELETON – MUSCLE STRUCTURE: |
|WEIGHT: kg |
|HEIGHT: cm |
|SKIN: |
| |
|NASO - PHARYNX – HEARING: |
| |
|BREATHING APPARATUS: TABACCO CONSUMPTION: g/day |
|PACKETS/YEAR: |
|CARDIO-VASCULAR APPARATUS: PULSE RATE: |
|BLOOD PRESSURE: |
| |
|DIGESTIVE APPARATUS: TEETH: |
| |
|GENITO-URINARY APPARATUS: |
| |
|ENDOCRINAL/THYROID FUNCTIONS: |
|NERVOUS SYSTEM: REFLEXES: |
| |
|Psyche: |
|Does the candidate have specific therapeutic needs? |
|please specify the nature and reason(s) for this therapy: |
| |
|Last vaccination dates and tuberculin test: |
| |
|Observations: |
| |
| |
| |
| |
| |
|BLOOD TESTS: |
|(CARRY OUT ALL OF THE TEST LISTED BELOW) (RESULTS MUST BE LESS THAN THREE MONTHS OLD) |
| |
|FILL-IN EACH ITEM BELOW BY HAND OR ATTACH THE LABORATORY RESULTS. |
|HAEMATOLOGY: | | | |
| | | | |
|Hb/Hgb |g |Leukocytes |103/mm3 |
| | | | |
|mcv |µ3 |Poly N |% |
| | | | |
|MCHC |% |E |% |
| | | | |
|RED BLOOD CELL: |10g/mm3 |B |% |
| | | | |
|Hematocrit | |Mono L |% |
| | | | |
| | |M |% |
|PLATELET COUNT: | | | |
| | | | |
|Urine Protein blood |sugar |Ketone or Acetone Bodies | |
| | | | |
|Observations: | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
|Conclusions : |
| |
| |
| |
| |
| |
I, undersigned, guarantee that the candidate presents to date no contagious or parasitic disease in evolution.
I certify the exactness of the information above.
Full name (in capital letters) and the address of the consulted Doctor of Medicine.
(or doctor’s stamp)
Date:
Signature:
← please SEND THIS MEDICAL CERTIFICATE IN A SEALED ENVELOPE, MARKed "MEDICAL SECRET", TO THE FOLLOWING ADDRESS:
HQ INFIRMARY,
SD Security, Health & Safety Division,
ITER Organisation, Building 06
ROUTE DE VINON SUR VERDON
13067 SAINT PAUL LEZ DURANCE
-----------------------
[pic]
[pic]
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- tampa general medical group medical records
- hackensack medical center medical records
- jfk medical center medical records
- certificat inmatriculare auto
- document confirmare anaf certificat digital
- anaf document confirmare certificat digital
- reinnoire certificat anaf confirmare
- anaf reinnoire certificat digital
- pierdut certificat inmatriculare
- anaf certificat digital
- certificat de radiere auto
- anaf inregistrare certificat digital