FORM B

TO BE FILLED IN BY THE DOCTOR

This form is to be completed by the doctor after reading through the Applicant’s Medical History Form (Form A).

Note to Candidate: Please hand this Form and the accompanying letter to the doctor examining you and ask her or him to return them to your Servants Home Team Coordinator.

Note for the Doctor: This applicant is applying for a demanding overseas assignment. For this reason a form has been devised to help detect any signs of ill-health which could if undiscovered lead to serious loss of time, expense or termination of service. Thank you for taking care in completing it.

Please read through Form A that has been filled in by the applicant, then complete Form B.

Because this applicant will be serving an underprivileged community overseas through a registered charity we would ask that you keep any charge to as low a rate as possible. Thank you for your assistance.

Name of applicant ______

Likely country of service ______

Likely length of service ______

EXAMINATION BY DOCTOR

GENERAL CONDITION

Condition and appearance: ______

Weight: ______

Height: ______

Body Mass Index: ______

Anaemia: ______

Jaundice: ______

Signs of thyroid disorder: ______

Hands and nails: ______

Lymph glands:______

Oedema:______

EYES

Pupils: ______

Signs of cataracts:______

Fundi: ______

State of conjunctivae: ______

Other:______

Ears: ______

Nose/sinus: ______

Mouth/fauces: ______

Teeth: ______

CARDIO-VASCULAR

Pulse Rate: ______

Rhythm: ______

BP(1): ______

Repeat if over 140/90 (2): ______

Heart sounds: ______

Heart size: ______

Any sign of heart failure: ______

RESPIRATORY AND CHEST

Chest movements: ______

Percussion: ______

Breath sounds: ______

Breast examination (for women aged 45 and over): ______

GASTRO-INTESTINAL

Abnormal swelling: ______

Tenderness on palpation: ______

Masses: ______

Hernias: ______

External genitalia (men – if indicated only): ______

Organomegaly: ______

Rectal examination (if indicated): ______

Pelvic examination (if indicated): ______

NEUROLOGICAL

Power:______

Sensation:______

Reflexes: ______

Coordination: ______

Gait: ______

BACK AND LEGS

Painful or swollen vertebrae: ______

Straight-leg raising: ______

Varicose veins: ______

Plantar reflexes: ______

Condition of feet: ______

Hip or knee abnormalities: ______

SKIN/HAIR/NAILS

Fungal infection: ______

Sun-induced skin changes: ______

Abnormal hair loss/growth: ______

Any other abnormalities: ______

PSYCHOLOGICAL

Signs of abnormal anxiety of stress: ______

Signs of depressive illness: ______

Signs of high alcohol intake: ______

Any other abnormal features: ______

TESTS AND INVESTIGATIONS

Please arrange the following investigations where indicated and enclose results (not required for children under 18 unless indicated).

Required Tests:NormalAbnormal

Urine (sugar, albumin, blood)______

Full Blood Count______

Liver Function tests______

Renal Function (creatinine)______

Hepatitis A antibodies ______

Hepatitis B antibodies ______

Test only if Clinically Indicated

Fasting lipids/glucose______

Cervical smear (where relevant)______

Blood group (if not known)______

HIV (where requested)______

Chest Xray______

Please specify any other investigations you have felt it necessary to carry out :

OUTCOME

Review of applicant’s health problems:

After discussing with applicant please comment on the following:

Any problems in applicant’s family history? ______

Any problems in applicant’s past history? ______

Any problems in applicant’s present condition? ______

Any problems found on medical examination?

______

Please give your opinion on the medical fitness of this candidate to withstand the demands of overseas service, often far from medical help ______

Are there any conditions you would place? ______

______

Thank you for completing this Form

Signed ______Date______

Name ______

Address ______

Phone No ______Fax No ______

Email ______

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