Immigration Physical Examination Form
Personal Information
Full Name
Date of Birth
Passport Number
Nationality
Address
Medical History
Have you ever had any of the following?
Tuberculosis
Hepatitis
Diabetes
Hypertension
None
Other (specify)
Physical Examination
Height (cm)
Weight (kg)
Blood Pressure
Pulse
Vision
Hearing
Physician's Remarks
General Remarks
Additional Findings
Certification
Physician Name
License Number
Signature
Date