Immigration Physical Exam
Applicant Information
Full Name
Date of Birth
Gender
Male
Female
Other
Country of Origin
Passport Number
Exam Date
Medical History
Review of Medical Conditions (if any)
Medications
Allergies
Vaccination History
Vital Signs
Height
Weight
Blood Pressure
Heart Rate
Temperature
Physical Examination
General Appearance
Head, Eyes, Ears, Nose, Throat
Chest/Lungs
Cardiovascular
Abdomen
Extremities
Neurological
Skin
Laboratory & Radiology Findings
Tuberculosis Test
Syphilis Test
HIV Test
Other Lab Test(s)
Chest X-Ray
Physician Information & Signature
Physician Name
License Number
Date
Physician Signature
Comments/Recommendations