Migrant Health Form
Migrant Health Form
Migrant Health Form
PART A
(TO BE COMPLETED BY PHYSICIAN AND APPLICANT)
Dependants: Yes No If yes please list ages ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
(b) Diabetes?
(p) Leprosy?
(q) Malaria?
YES NO
(v) Family history of diabetes, high blood pressure, tuberculosis, mental illness, fits?
2. Have you had any acute respiratory tract infection within the last 3 months?
5. Do you Smoke?
If you answered yes to any of questions 1, 2, 3, 4 or 5 please give details below or on separate sheet provided on page 5.
8. Are you now in good health? Yes No If no, give details below
9. Are you now pregnant? Yes No Not applicable If yes, how many months _________
PART B
PHYSICAL EXAMINATION
(TO BE COMPLETED BY EXAMINING PHYSICIAN)
2. Height ________ft ______inch Weight _______lbs (in under clothes) Waist _______inches
Chest Measurement: On inspiration ______inch On expiration _______inch
3. Blood Pressure: lying down __________ sitting __________
4. Pulse rate: at rest_________ after 1 minute of brisk activity _________
5. Please tick ‘yes’ if you find abnormality in any of the organ systems below or tick ‘no’ if they are free of disease or
abnormality.
Yes No Yes No
(a) Skin (g) Cardiovascular system
(b) Throat & mouth (h) Respiratory system
(c) Eyes (i) Musculo-skeletal system
(d) Ears (j) Nervous system
(e) Nose (k) Genito-urinary system
(f) Gastrointestinal (l) Mental Status
If you ticked ‘yes’ to any of the questions above please provide details in space below or on blank page provided.
PART C
SCREENING AND DIAGNOSTIC EVALUATION
(TO BE COMPLETED BY EXAMINING PHYSICIAN)
1. Chest Radiograph: X-ray number ________ Date performed________ Result: Normal / Abnormal (circle)
(Please note that chest x-ray MUST NOT be more than 6 months old for new applications and not more than 2 years old for renewal
applications. Tuberculin test can be performed on pregnant women in lieu of chest x-ray. Chest x-ray is not required for persons
under 15 unless clinically indicated or tuberculin test strongly positive).
(Please note ECG is only required for persons over the age of 40 years and or with significant cardiovascular risk)
3.Urinanalysis: Date performed _______ Albumin ___ Glucose __ Blood _____ other positives ___________
(Please note that proof of hepatitis B immunization and a negative Hepatitis B test is required by
ALL workers in the health and hospitality industries. Children under the age of 15 are not required
to do serological test for HIV, syphilis or Hep B unless it is clinically indicated)
5. Other Tests:
Test Date performed Result
b. Drug Screen:
Please note that children under the age of 15 are not required to do drug screen unless indicated from history or clinical exam.
Drug screen is only mandatory for persons being employed by the Turks and Caicos Islands Government.
Please attach laboratory and other reports to this application for submission to the NHIB
6. Vaccinations
Proof of vaccination against Measles, Mumps, Rubela, Polio, Tetanus, Diphtheria, and Pertussis are required
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I _______________________________, (the applicant / the legal Guardian) hereby acknowledge that this medical
evaluation is being performed for the purpose of determining my eligibility for residency in the Turks and Caicos Islands
and as such I consent to the review this medical report by duly authorized officers within the Ministry of Health and any
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