Medical Procedure – Ever Green Medical Center

MEDICAL REPORT
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 ……………………….

1. MEDICAL INVESTIGATIONS

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 TRACK ABDOMEN OTHERS
HERNIA
VARICOSE VEINS
EXTREMITIES
DEFORMITIES
SKIN
VENEREAL DISEASES CLINICAL
C N S
PSYCHIATRY

1. LABORATORY INVESTIGATIONS

TYPE OF LAB INVESTIGATIONS	RESULTS
URINE SUGAR ALBUMIN BILHARZIASIS (IF ENDEMIC)
STOOL ROUTINE 1. HELMINTHES 2. GIARDIA 3. BILHARZIASIS (IF ENDEMIC CULTURE) 4. SALMONELLA SHEGELLA V CHOLERA (IF ENDEMIC)
BLOOD HAEMOGLOBIN THICK FILM FOR 1. MALARIA 2. MICRO FILARIA SEROLOGY 1. F. B. S 2. L. F. T, S 3. CREATININE ELISA 1. HIV 1.2 TEST 2. HBs Ag 3. Anti HCV VDRL TPHA (IF VDRL POSITIVE)
PREGNANCY TEST

Notes about medical and laboratory investigations

………………………………………………………………………………………..

…………………………………………………………………………………………

Dear, Sir,…………………………………………..

Mentioned above is the medical report for Mr. / Mrs

……………………………………………………………………………………….

He / She is fit

For the above mentioned job

Unfit

Chief Physician

Stamp Name : …………………….

Signature :

……………………………………………………………………………………………..

(1) Stamp of the medical center on the photo and application

(2) Chest : Free of pathological changes

the medical report and x-ray should be submitted to the health authorities in GCC countries.