Form 103b - Medical Report Of Ministerial Candidate - The United Methodist Church
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1
2THE UNITED METHODIST CHURCH
MEDICAL REPORT OF MINISTERIAL CANDIDATE
To: The Board of Ordained Ministry, South Carolina Conference
1. Complete Physical with laboratory tests is required by Board for completion of the medical examiner’s report.
2. Indicate to the physician the address of the District Office who will receive this report:
Part I: MEDICAL HISTORY REPORT
To be completed by the candidate.
Name:
Date of birth: ________
Address _________________________________________________________________
Street
City
State
Zip
E-mail __________________________________________________________________
Marital Status: Single, never married _______ Married, in first marriage ______ Married, in second or more______
Widowed ______
Separated ______
Divorced ______
Number of children ____________
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1. Check if you have ever had:
Arthritis
Diabetes
High blood pressure
Poliomyelitis
□
□
□
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Asthma
Epilepsy
Kidney trouble
Rheumatic fever
□
□
□
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Cancer
Heart trouble
Peptic ulcer
Tuberculosis
□
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2. Check if any member of
Arthritis
High blood Pressure
Poliomyelitis
Diabetes
□
□
□
□
your family has ever had:
Asthma
Epilepsy
Kidney trouble
Rheumatic fever
□
□
□
□
Cancer
Heart trouble
Peptic ulcer
Tuberculosis
Explain: _________________________________________________________________________________
3. What vaccinations or inoculations have you had? Give dates: _____________________________
________________________________________________________________________________
4. Have you ever had an electrocardiogram? If so, give date and attending physician: ____________________
___________________________________________________________________________________
5. Have you ever had a serious accident or operation? Explain: ______
________________________
___________________________________________________________________
______________
□ Yes □ No
□ Yes □ No
6. Have you any impairment of sight?
Hearing?
7. If your weight has changed in the past two years, state approximate loss/gain _______________________
□ Yes □ No
8. Have your ever been rejected for life insurance?
□ Yes □ No
9. Have your ever received treatment for alcohol or drug habit?
□ Yes □ No
10. Do you smoke?
If yes, How Long?
How much? ______________
11. Have you ever been under observation or treatment in any hospital or sanitarium for a physical or nervous
□ Yes □ No
condition?
Explain: ____________________________________________________
.
The above statements are true and accurate to the best of my knowledge
Signature:
Date: ____________________
7/2013
103a
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