Application For Quota / Nonquota Immigrant Visa (Page 3 of 3) in pdf

Application For Quota / Nonquota Immigrant Visa Page 3

FA Form no. 11

FOREIGN SERVICE OF THE PHILIPPINES

(Photograph

Philippine Embassy

of medical

Berlin, Germany

examinee)

MEDICAL EXAMINATION FOR VISA APPLICANTS

At the request of the Philippine Embassy, Berlin, Germany, I certify that on the ______

day of ______________, 20____ at ______________________ I examined:

……………………..……..….…………………………………………………..……..….……………………

(First Name)

(Middle Name)

(Surname)

_______ (Age) ___________ (Sex) _________________ (Citizenship) and that under the

Philippine Immigration Regulations, the applicant should be classified as follows (check the

appropriate class):

A. Idiots, insane person, person who had been insane, person afflicted with epilepsy or

loathsome or dangerous contagious disease such as: tuberculosis, venereal disease,

trachoma, ringworm of scalp, nail or beard, actinomycosis, favus blastomycosis,

mycetoma, leprosy, yaws, amebiasis, leishmaniasis, filiarisis, schistosomiasis, parago

nomiasis.

B. If not Class A: Persons having diseases or defects that will impair their ability to earn a

living as to make them likely to be a public charge.

C. Persons having diseases or defects that do not come under Class A or B.

D. Not physically or mentally defective or diseased.

MEDICAL RECORD

1. Pertinent health information (Medical History):

2. Significant findings on physical examination:

3. Laboratory examinations (ATTACH LABORATORY RESULTS):

A. Stool

B. Urine

C. Blood Khan

D. Other examination indicated

4. CHEST X-RAY REPORT

5. REMARKS

………………………..…..….………………

(Name and Signature of Examiner)

(Hospital)

Application For Quota / Nonquota Immigrant Visa Page 3