Doctor's Medical Certificate for Aupair Programme

To be completed by your Doctor

 

Surname: First name: Female: Male:
Date of birth:  day  month  year Height:  metres Weight:  kilos
Address:
Tel:
Fax:





1. Does the applicant presently suffer from or has ever had the following?

 

Yes

No

 

Yes

No

 

Yes

No

Allergies:

Anaemia:

Anorexia:

Apendicitis:

Arthritis:

Asthma:

Bulimia:

Chicken Pox:

Depression:

Diabetes:

Diziness/Fainting:

Eye problems:

Epilepsy/Convulsions:

German Measles (Rubella):

Glandular Fever:

Heart Disease:

Hepatitis:

Hernia:

Herpes (cold sores):

Kidney Disease:

Malaria:

Measles:

Menstrual problems:

Miscarriage:

Migraine/Headaches:

Mumps:

Nervous Illness:

Polio:

Rheumatic Fever:

Scarlet Fever:

Tuberculosis:

Venereal Disease:

Ulcers:

If answered Yes to any of the above, please give details and dates as applicable:

 

2. Please indicate if the applicant has been immunised against the following:

 

Yes

No

Date

 

 

Yes

No

Date

Tetanus:

 

Mumps:

Typhoid:

 

Measles:

Diptheria:

 

Whooping Cough:

Tuberculin Test:

 

German Measles (Rubella):

Polio:

 

 

 

 

 

 

3. Is the applicant currently, to the best of your knowledge, a likely carrier for any infectious disease, such as Hepatitis B or HIV virus?  Yes  No

If answered yes, please give details:

 

4. Is the applicant currently, or has the applicant ever been treated/councelled or received medication for a nervous condition, eating disorder, depression or emotional disorder?  Yes  No

If answered yes, please give full details and dates. Please provide comments on the applicant's present condition and well being:

5. Has the applicant, to be best of your knowledge, ever had any criminal convictions or charges filed against them?  Yes  No

If answered yes, please give full details.:

6. Does this applicant have any history of physical, emotional or sexually related problems that you might wish a family to know as they consider whether the applicant is a suitable person to live in their home and care for their small children for up to 2 years?  Yes  No

If answered yes, please give full details:

Name of doctor:

Address:

Tel:

Fax:

Doctor's stamp or seal of the practice:

Signature:

Date:

 day

 month

 year

 

 

Please print and take to medical practitioner.  Make a copy for yourself and send the original to the Agency

EMAIL COMPLETED FORM TO: kiwia.redirect@gmail.com OR SEND BY FAX TO: +6498134426