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 |

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MEDICAL FILE TO BE DULY COMPLETED BY YOUR DOCTOR OF MEDICINE

MEDICAL CERTIFICATE

|CANDIDATE’S FIRST AND LAST  NAME: |Nationality: |

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|FRENCH SOCIAL SECURITY N° (If applicable) |

|MEDICAL HISTORY: |

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|MEDICAL HISTORY IN RELATION TO YOUR PROFESSION: |

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|HISTORY OF PROFESSIONAL AND/OR MEDICAL RADIATION EXPOSURE - DOSE RECORDED: |

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|EYESIGHT COLORS |NEAR |FAR |

|visual acuity |sc |cc |sc |cc |

|right eye | | | | |

|left eye | | | | |

|MUSCULOSKELETAL SYSTEM - SKELETON – MUSCLE STRUCTURE: |

|WEIGHT: kg |

|HEIGHT: cm |

|SKIN: |

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|NASO - PHARYNX – HEARING: |

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|BREATHING APPARATUS: TABACCO CONSUMPTION: g/day |

|PACKETS/YEAR: |

|CARDIO-VASCULAR APPARATUS: PULSE RATE: |

|BLOOD PRESSURE: |

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|DIGESTIVE APPARATUS: TEETH: |

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|GENITO-URINARY APPARATUS: |

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|ENDOCRINAL/THYROID FUNCTIONS: |

|NERVOUS SYSTEM: REFLEXES: |

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|Psyche: |

|Does the candidate have specific therapeutic needs? |

|please specify the nature and reason(s) for this therapy: |

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|Last vaccination dates and tuberculin test: |

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|Observations: |

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|BLOOD TESTS: |

|(CARRY OUT ALL OF THE TEST LISTED BELOW) (RESULTS MUST BE LESS THAN THREE MONTHS OLD) |

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|FILL-IN EACH ITEM BELOW BY HAND OR ATTACH THE LABORATORY RESULTS. |

|HAEMATOLOGY: | | | |

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|Hb/Hgb |g |Leukocytes |103/mm3 |

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|mcv |µ3 |Poly N |% |

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|MCHC |% |E |% |

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|RED BLOOD CELL: |10g/mm3 |B |% |

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|Hematocrit | |Mono L |% |

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| | |M |% |

|PLATELET COUNT: | | | |

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|Urine Protein blood |sugar |Ketone or Acetone Bodies | |

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|Observations: | | | |

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|Conclusions : |

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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

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