A M Health Care

PERSONAL DETAILS

Name

Nationalit

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Yate o

a Sinan pt V4 @qMAlt@ronecamny AINo pla

REVIEW OF ‘SYsTEms

TO WHOM IT MAY CONCERN

ality: “Cheah Tes(a m(chae} 10/Passport Number: EP 1S) 7 36

i Oa) 188 sender eg ps ONG

DHVEr Destination: Canadh

f

}— Revers ee any of the following? fe es

Ct * Hasunenes % . Loss of memory

0 Difficulty with vision/ Wear lenses or glasses No ee ‘tr i es

Oo Dizziness/Vertigo No Se

QO Tiredness or falling asl aoe

8 asleep during the day No QO Back pain

QO Unable to tolerate heat or cold O Joint pain or swelling 0

{ QO Shortness of breath PN or without exertion if, 0 History of broken bones 0

O Sneezing 0 Swelling of the legs

QO Cough N QO Skin problems {rash, eczema 120. NO

QO Allergies NO Cl High blood pressure (20

aa Carpal tunnel Syndrome _ No poe e 7G) Dlahetes NO

No you smoke? No If yes, what do you co smoke 3nd how many per Cay? _

Do you ¢rink alcohol? If yes, what do you dzink and how my ich?

Vaccin

0

r

O Are you currentiy under the treatment or care of a physiélan cr cther health care prov vider r

ation No

= ee

Current medical condition (if any, list those that you are currently receiving treatment for Date, month and year)

CG Do you have an to any medications or other substances? If yes, please specify.

0

Do you have any condition (physical, medical or Psyctiological) that would require accommodations in order for you to

preform you job? if yes, please specify.

D ae

PHYSICAL EXAMINATION

Height

Heart

Skin

Other

v

Weight oe ai

Eye: h Eyes:

Vision: Right Eye: 6 6 f ee Both Eye aie

Chest/Lungs

$4Sa ma Ff th av

Abdomen P O* And Ni of cant Soto”

Musculoskeletal N orm a

Newrotoeeat_— MON NOFA Eva “alto,

eae CS

Application’s Clearance

i as an applicant, authorize the release to the issue of all information contained on this examination form and all

1

i It of my examination.

other forms generated as a direct resu

hereby understand that, due to the nature of this examination (ONLINE EXAMINATION), take fulf Fegppinp/bilty

for the above information. ae Aes

i hereby agree and confirm that all my personal information and data sated above are accusate. understand tat

false, inaccurate, or missing information may invalidate this certificate. hereby consent andauthofizaiGreek

. i > > 2 da ind/or to rétedse mM

Medicine of Tomorrow to process any of my datas (including any personal sensitive data) and/or to

pre-employment physical examination certificate.

NAME OF APPLICANT SIGNATURE OF APPLICATION

Ategawi ‘Tesjamichae!

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