Medical Form NAME OF APPLICANT – AS IT APPEARS IN PASSPORT
Has the applicant been hospitalized for more than three days?
Have you any knowledge that the applicant has ever been a victim of physical, emotional or sexual abuse?
Does the applicant have any history of physical, emotional or sexually related problems that you might wish an American 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 a year?
Is there any history of nervous or emotional problems, depression or abuse (sexual, emotional or physical) in the applicant’s family
No If yes, please give details and dates
Has the applicant, to the best of your knowledge, ever had any criminal convictions or charges filed against them?
Do you have access to the patient’s full medical history?
Please use this space to give any additional relevant information
I have examined and/or reviewed medical notes of (tick as applicable) the Please add your Doctor’s or medical practice stamp here. above named applicant and I find him/her to be capable of benefitting from and fully participating in an Au Pair in America program.
No If no, did you fully understand all the questions asked on the form?
Signature Medical Form INSTRUCTIONS PART A To be completed by Applicant and reviewed by Doctor PART B To be completed by Doctor 1 Please complete this form immediately. 3 Post or fax the other copy to the London office 2 Make a copy of your completed form.
immediately or give it to your interviewer to forward. Keep one copy (original or photocopy) to take with you to the 4 Please note the Doctor completing this form may not United States. PART A – to be completed by Applicant & reviewed by Doctor
Please note that withholding or falsifying any information may result in the applicant being withdrawn from the program
NAME OF APPLICANT – AS IT APPEARS IN PASSPORT
Next of kin – please give details of the relative or person we can contact in case of an emergency when you are in the US
Are you covered by additional insurance beyond that provided by the Au Pair in America program?
If yes, give details and attach a photocopy of the policy documents (write your name clearly on each page)
Tick the appropriate box if you presently suffer from or have ever had:
If you have ticked any of the above, give details including dates as applicable
37 Queen’s Gate London SW7 5HR UK Tel: +44 (0)20 7581 7322 Fax: +44 (0)20 7581 7345
Medical Form NAME OF APPLICANT – AS IT APPEARS IN PASSPORT
Other than to complete this medical form, when was the last time you visited a Doctor and why?
Have you ever received counseling and/or medication for a nervous condition, eating disorder, depression or emotional problem?
Have you ever been a victim of sexual, emotional or physical abuse?
Is there any history of nervous or emotional problems, depression or abuse (sexual, emotional or physical) in your family background?
Tick the appropriate box if you suffer from any allergies:
If you have ticked any of the above, give full details
Is your physical ability restricted in any way?
your health (e.g. alcohol, cigarettes, drugs)?
Do you carry any infectious diseases such as
Hepatitis B or the HIV virus in your blood?
Do you have any chronic or recurring illnesses?
If you have ticked any of the above, give full details including names of any medication
In view of the nature of the program for which you have applied, it is the practice of Au Pair in America and EduCare in America to request acriminal record check.
Have you ever been convicted of a criminal offence, or are you at present the subject of criminal charges?
I understand and agree that American host families may have access to this Medical Form and give permission to the Doctor completing Part B toreview all my responses in Part A of this form and to provide or discuss additional medical information, if requested to do so by Au Pair in America.
Should an emergency situation arise, I authorize any medical provider to release information regarding my condition to Au Pair in America or theirinsurance provider/emergency assistance services and understand that they can contact my next of kin without my prior consent.
The above information is correct to the best of my knowledge and I hereby give permission for emergency medical care to take place should itbe necessary. I also understand that withholding or falsifying any information may result in me being withdrawn from the program. Signature Note: This form must be completed and signed by the applicant. Remember to keep a copy of your fully completed medical form and take it with you to the US. Medical Form NAME OF APPLICANT – AS IT APPEARS IN PASSPORT PART B – to be completed by Doctor Are you related to the applicant? No Please note relatives may not complete this form. As an au pair or companion in America, the applicant will be living for an extended period of time in the home of a family with young children. It is therefore important that we are advised of any physical, mental or emotional health problems or family history issues which may have a bearing on the applicant’s ability to carry out his/her duties appropriately. Please note that withholding or falsifying any information may result in the applicant being withdrawn from the program.
Please review the information provided in PART A and give your opinion of the applicant’s general state of health:
Please ensure that the applicant is currently immunized/tested against the following:
Has the applicant been immunized against tuberculosis (TB)?
If no, please provide details of a tuberculin test or attach the results of a recent chest x-ray. Test date
(Please note: positive test results will require additional information on dates the applicant had TB, details of any treatment and a copy of a recent chest x-ray.)
Please also indicate whether the applicant has been immunized against the following:
Tick the appropriate box if there are any abnormalities to the following systems:
If you have ticked any of the above, please give details and dates
Is the applicant, to the best of your knowledge, a likely carrier of any infectious disease, such as Hepatitis B or C, or the HIV virus?
(The applicant does not need to be tested.)
Have you noticed any changes in weight or eating habits for the applicant that may give rise to concern regarding an eating disorder?
Is the applicant currently or has the applicant ever been treated/counseled or received medication for a nervous condition, eating disorder,
If yes, give details and dates and comment on the applicant’s present emotional well being