Name of Primary Health Center/ Clinic/ Hospital

Address
Phone and Fax
IDENTITY
1
2
3
4
5
6
7
8

Name
Date of Birth
Place of Birth/ Nationality
Sex
Status
Occupation
Register Number
Address

:
:
:
: male/ female
: single/ family, children:
:
:
:

PHOTOGRAPH

MEDICAL CONDITION IDENTIFIED

please tick the below category
working/ final diagnosis

ICD Code

None
Minor symptoms/ non significant condition
Contagious Disease
Physical Impairment or Disability
Mental Disorder
Addiction (abuse) of specific substances
Chronic Disease: DM, Hypertension etc
Pregnant
Other significant condition

TREATMENT AND RECOMMENDATION

Supportive Exams

Treatment

1
2
3
4
5

Follow Up/ Referral: Yes or No

Immunization and Schedule:

By Whom
by GP
by specialist, specify:
2.

Physician's signature and name

Date:

schedule
1.

MEDICAL HISTORY
No Have you ever had or needed:
No
1 Illness or Injury requiring hospitalization or surgical intervention?

Yes

please detail below

Tuberculosis or treatment for tuberculosis or an abnormal chest x-ray or chronic

2 cough or bloody cough or a close contact with a person with TB?
An infectious or communicable disease lasting more than 2 weeks such as
3 jaundice, hepatitis, HIV-AIDS etc?
4 Eyes or ears problems such as difficulty hearing or seeing etc?
5 Neurological disease such as seizures, epilepsy, stroke, etc?
Nervous or anxiety or depression or mental illness such as autism, mental
6 retardation etc?
7 Cardiovascular disease such as high blood pressure, heart disease etc?
8 Blood or Hematologic disorder such as anemia or thalasemia etc?
9 Asthma or shortness of breath or chronic cough or other lungs disease?
Stomach or digestion problem or liver disorder or bowel disease or other
abdominal symptoms such as heart burn, indigestion, chronic diarrhea, blood in
10 stool etc?
11 Kidney or bladder disease or prostate problem?
12 Diabetes or other endocrine disorder?
13 Muscle, joint and bone problems?
14 Cancer or tumor?
15 Sexual transmitted disease?
16 Tattoo or body piercing or history of blood transfusion?
17 Skin disorder?
18 Reproductive or genital disorder?
Any other illness, injury or medical condition more than 2 weeks or recurring
19 condition not previously mentioned? Any loss of weight in last 6 months?
20 History of family disease such as dialysis, cancer, coronary heart disease etc?
For Female only
Are you pregnant? What is the expected date of birth? How is the history of previous
pregnant?
No Additional Medical Information
Are you taking medications? (name of medicines, dosage, length of consumption
1 etc)
2 Do you have any drug, food or other things allergies?
3 History of torture or violence
4 How many months have you displaced from home?
5 Habits/ history of habits/ drug abuse:
Alcohol (how many years/ when, how much units per week etc)
Smoking (how many years/ when, how many pieces per day etc)
Name of drugs (how many years/ when, dosage, any treatment etc)
6 Immunization History
BCG
DPT
Polio
Measles
DT
TT
Hepatitis B
Other:
I hereby declare and certify that the information I have provided on this form is
true and complete (correct)
Migrant's Signature (over 16 years old age and relationship) or Finger Print and
name

Date

PHYSICAL EXAMINATION
Was a chaperone present during the examination? (name and relationship)
Was an interpreter present during the examination? (name and relationship)
1 Date of Examination
2 BMI (weight-KG/ height-M2)
Weight (KG)
Height (cm)
Waist circumference (cm, >=20 years old
age)
Head Circumference (cm, <18 months old
3 age)
Left Mid Arm Circumference (abnormal
BMI, cm)
4 Visual Acuity
Uncorrected
Corrected
Pin Hole
Ishihara Test
Blood Pressure ( >=11 years old age, initial,
5 repeated, mmHg)
Pulse Rate and Rhytm

yes/ no
yes/ no
please specify if abnormal

right

left

Respiratory Rate and type of respiratory

Temperature (per indication)
normal abnormal

please specify if abnormal or pregnant

General Appearance (including visible

6 disability, anemia and jaundice)
7 Mental, Cognitive and Intelligence Status
Developmental milestones (< 5 years old
8 age)
9 Eyes (including funduscopy)
Ears (including hearing), Nose and Mouth
10 (including throat and teeth)
11 Skin, Lymph Nodes and Breast
12 Cardiovascular System
13 Respiratory System
14 Gastrointestinal System
(including hernia, rectal, liver and spleen)
15 Endocrine System
Genito-Urinary System (including prostate
16 exam if needed)
17 Musculo-skeletal System
18 Neurological System
19 Extremity
20 Pregnant

Yes/ No

Physician's signature and name

Date: