Medical Report Form - Registration Of Skilled Professional Act Page 2
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33. Does the applicant have any history of dependency on drugs, alcohol or other controlled
substances:
Yes
No
4. Has the applicant or any member of his/her family ever suffered from any mental disorder, fits or
epilepsy:
Yes
No
C. EXAMINATION RESULTS
1.
HEART:
2.
LUNGS:
3.
KIDNEY:
4.
LIVER:
5.
EYES
6.
X-RAY:
7.
BLOOD
HBG%
SUGAR
DEPOSIT
D: APPLICANT'S DECLARATION:
1. I declare that the details given by me on this form to the medical examiner are true and correct in
every respect.
2. I agree that I will undergo, at my expense, any further medical examinations that may be required
by the Skilled Professionals Evaluation Committee
3. I authorize that the medical examiner who completes this form to release to Skilled Professionals
Evaluation Committee, or its medical consultants, any information acquired with regard to this
examination.
4. I agree that all the information contained in this form is to evaluate my application under the Act.
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