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    Residence Form - Medical Examination PRINTABLE

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    Angelica Escalante
    This document is a preliminary medical examination form for a passport applicant from Belize. It collects information about the applicant's personal details, medical history, and current health status. A physician examines the applicant and indicates whether they have any issues with their eyes, ears, heart, lungs, mental status, or infectious diseases. The physician provides their diagnosis, notes any abnormal test results, and signs the form to confirm the applicant's fitness for travel.

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    Download as PDF, TXT or read online from Scribd

    Residence Form - Medical Examination PRINTABLE

    Uploaded by

    Angelica Escalante
    35 views2 pages
    This document is a preliminary medical examination form for a passport applicant from Belize. It collects information about the applicant's personal details, medical history, and current health status. A physician examines the applicant and indicates whether they have any issues with their eyes, ears, heart, lungs, mental status, or infectious diseases. The physician provides their diagnosis, notes any abnormal test results, and signs the form to confirm the applicant's fitness for travel.

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    application form medical -amnesty 2022 program

    Original Title

    Residence Form - Medical Examination PRINTABLE (1)

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    This document is a preliminary medical examination form for a passport applicant from Belize. It collects information about the applicant's personal details, medical history, and current health status. A physician examines the applicant and indicates whether they have any issues with their eyes, ears, heart, lungs, mental status, or infectious diseases. The physician provides their diagnosis, notes any abnormal test results, and signs the form to confirm the applicant's fitness for travel.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    35 views2 pages

    Residence Form - Medical Examination PRINTABLE

    Uploaded by

    Angelica Escalante
    This document is a preliminary medical examination form for a passport applicant from Belize. It collects information about the applicant's personal details, medical history, and current health status. A physician examines the applicant and indicates whether they have any issues with their eyes, ears, heart, lungs, mental status, or infectious diseases. The physician provides their diagnosis, notes any abnormal test results, and signs the form to confirm the applicant's fitness for travel.

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    BELIZE

    Nationality & Passport Department


    PRELIMINARY MEDICAL EXAMINATION
    EXAMEN MÉDICO PRELIMINAR

    HOSPITAL / MEDICAL CENTER HOSPITAL/CENTRO MÉDICO

    A APPLICANT INFORMATION / INFORMACIÓN DEL SOLICITANTE

    A01 LAST NAME(S) A02 FIRST NAME(S)


    APELLIDO(S) NOMBRE(S)
    DAY / MONTH / YEAR /
    DÍA MES AÑO
    A03 DATE OF BIRTH A04 NATIONALITY A05 PASSPORT NUMBER
    FECHA DE NACIMIENTO NACIONALIDAD NUMERO DE PASAPORTE

    SINGLE MARRIED DIVORCED


    A06 GENDER MALE FEMALE A07 MARITAL STATUS SOLTERO(A) CASADO(A) DIVORCIADO(A)
    GÉNERO MASCULINO FEMENINO ESTADO MARITAL
    WIDOWED COMMON-LAW
    VIUDO(A) CONSENSUAL

    B QUESTIONS TO BE ANSWERED BY APPLICANT / PREGUNTAS QUE DEBE RESPONDER EL SOLICITANTE

    B01 HAVE YOU BEEN EXAMINED FOR MIGRATION TO BELIZE? YES NO


    ¿HA SIDO EXAMINADO PARA INMIGRACIÓN A BELICE? SÍ NO

    B02 HAVE YOU EVER BEEN TREATED IN A HOSPITAL? YES NO IF YES, SPECIFY BELOW /
    ¿HA INGRESADO USTED ALGUNA VEZ A UN HOSPITAL? SÍ NO SI RESPONDE SI, ESPECIFIQUE ABAJO

    LIST OF NAMES OF HOSPITAL CONDITIONED TREATED


    LISTA DE NOMBRES DE HOSPITALES CONDICIÓN TRATADA

    B03 HAVE YOU EVER SUFFERED FROM OR RECEIVED TREATMENTS FOR PLEURISY OR TUBERCULOSIS OF ANY KIND, OR ATTENDED A
    SANATORIUM, OR TUBERCULOSIS CLINIC, EITHER AS A IN-PATIENT OR AS AN OUT-PATIENT? YES NO
    ¿HA SUFRIDO USTED ALGUNA VEZ O HA RECIBIDO TRATAMIENTO PARA PLEURESÍA O TUBERCULOSIS DE CUALQUIER TIPO, O ASISTIDO A UN SANATORIO, O CLÍNICA DE SÍ NO
    TUBERCULOSIS, YA SEA COMO PACIENTE INTERNO O EXTERNO?

    B04 HAVE YOU EVER BEEN A PATIENT IN A MENTAL INSTITUTION? YES NO


    ¿HA INGRESADO USTED ALGUNA VEZ COMO PACIENTE A UNA INSTITUCIÓN MENTAL? SÍ NO

    B05 ARE YOU RECEIVING, OR HAVE YOU EVER RECEIVED A DISABILITY PENSION? YES NO
    ¿ESTÁ USTED RECIBIENDO, O HA RECIBIDO ALGUNA VEZ UNA PENSIÓN POR INCAPACIDAD? SÍ NO

    C QUESTIONS TO BE ANSWERED BY MEDICAL PHYSICIAN / PREGUNTAS QUE DEBE RESPONDER EL MÉDICO


    CHECK YES OR NO
    1. EYE TROUBLE OR TRACHOMA YES NO 12. STOMACH TROUBLE YES NO
    2. NOSE OR THROAT TROUBLES YES NO 13. RHEUMATISM OR JOINT TROUBLE YES NO
    3. EAR TROUBLE OR DEAFNESS YES NO 14. LUNGS DISEASE OR CHRONIC YES NO
    4. HEAD INJURIES YES NO 15. HAY FEVER OR ASTHMA YES NO
    5. BROKEN BONES YES NO 16. RHEUMATIC FEVER YES NO
    6. BACK INJURIES YES NO 17. HEART DISEASE YES NO
    7. HAEMORROHOIDS YES NO 18. FAINTING SPELLS YES NO
    8. RUPTURE YES NO 19. FITS OR SIEZURE YES NO
    9. KIDNEY OR BLADDER TROUBLES YES NO 20. NERVOUS DISORDER YES NO
    10. VENERAL DISEASE YES NO 21. TROPICAL DISEASE YES NO
    11. VARICOUSE VEINS YES NO 22. OPERATION/SURGERY YES NO

    REMARKS ON POSITIVE FINDINGS

    page 1 of 2
    Revised 02.2019. Ver. 02
    HEIGHT: WEIGHT: TEMP: PULSE:

    RESPIRATION: PHYSIQUE:

    VISION: (WITHOUT GLASSES) RIGHT EYE 20/ LEFT EYE 20/

    EARS (DRUM): RIGHT: LEFT:

    MOUTH: THROAT:

    NOSE: SPINE:

    HEART:

    BLOOD PRESSURE: SYSTOLIC:

    DIASTOLIC:

    ABDOMEN:

    HERNIA:

    GENITO - URINARY: PREGNANT:

    RECTUM:

    UPPER EXTREMITIES: LOWER EXTREMITIES:

    SKIN: LYMPHATIC SYSTEM:

    MENTAL DEVELOPMENT: DULL: NORMAL:

    BELOW NORMAL: PSYCHIATRIC ABNORMALITIES:

    BLOOD WASSERMAN IF INDICATED STOOL EXAM IF INDICATED

    URINALYSIS IF INDICAED (A) ALBUMEN (B) SUGAR

    (C) MICROSCOPIC

    REMARKS

    DIAGNOSIS

    PROGNOSIS

    ATTACHED ARE TEST RESULTS FOR : 1. HIV YES NO 4. OTHER YES NO


    2. VDRL YES NO
    3. TB YES NO
    DAY / MONTH / YEAR /
    DÍA MES AÑO

    DATE

    SIGNATURE OF APPLICANT
    [ MOTHER / FATHER ] SIGNATURE OF EXAMINING PHYSICIAN

    official LICENSE NO.:


    stamp
    page 2 of 2

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