Office Of The Chief Rabbi Pre-Departure Medical Examination Form
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1
2PRE-DEPARTURE MEDICAL
EXAMINATION FORM:
TO BE COMPLETED BY
DOCTOR
Date:
Name of Patient:
Date of Birth:
Sex:
Patient is regularly using the following medications:
List any Patient’s allergies, including to medications:
In your judgment, is there any condition, mental or physical, that might preclude Patient from
travelling?
I verify that Patient has the following vaccinations for his/her travel to destination:
NAME OF VACCINATION LAST ISSUE DATE
I have examined Patient, and have reviewed
his/her health history. It is my opinion that he/she is able to travel. I have examined Patient, and
have reviewed his/her health history. It is my opinion that he/she is NOT able to travel.
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Parent category: Medical