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Medical examination form
MEDICAL EXAMINATION FORM
Please indicate all pathological or abnormal findings
Name of the applicant:
Date of examination:
1. General Information
a. Do you personally know the person to be inured? (if No, the identity checked on the basis of:)
Personally known
Passport
ID
Driving License
b. Have you previously examined or treated the applicant?
Yes
No
When?
Why?
d. Are you related to the applicant?
Yes
No
2. Measurements
Height (without shoes in cm):
Weight (without clothes in Kg):
If overweight (Abdominal girth in cm / Hip measure in cm):
3. Skin
a. Are there any signs of skin disease (e.g. rashes, ulcers, swellings, etc.)?
Yes
No
What?
Where?
b) Are there any scars, suspicious naevi?
Yes
No
What?
Where?
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