Immigration Medical Exam Documentation
Applicant Information
Full Name
Date of Birth
Passport Number
Country of Origin
Address
Medical Examination Details
Date of Examination
Physician's Name
Clinic/Hospital Name
Clinic/Hospital Address
Medical History
Relevant Medical History
Medications
Allergies
Physical Examination
Physical Findings
Lab Tests Performed
Vaccination Status
X-Ray Results
Examiner’s Summary & Recommendations
Summary
Recommendations
Certification
Examiner Signature
Date