Application Form - Les Roches International School Of Hotel Management Page 4

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T O B E C O M P L E T E D O N L Y B Y A P H Y S I C I A N
Name of the patient
Date of Birth :
Day
Month
Year
Male
Female
Sex:
Blood pressure
MM/HG
Height (cm)
Weight (kg)
Pulse rate
C L I N I C A L E V A L U A T I O N
Please indcate if the patient has experienced any problems with the following :
Yes
No
Details
1.
Skin
2.
Head, Neck & Thyroid
3.
Eyes & Ears
4.
Mouth & Throat
5.
Chest, Breasts & Lungs
6.
Heart & Blood Vessels
7.
Digestive System
8.
Nervous System
9.
Skeletal, Muscular System
10. Urinary, Reproductive System
11. Others (specify)
Other comments
R E Q U I R E D L A B O R A T O R Y T E S T S / I N F O R M A T I O N
Tuberculin Skin Test (TST). Please indicate date and results in mm
or Blood Test :
Has the applicant been immunized against any of the following. Please specify the dates and number of doses.
Yes
No
Dates
Doses
Diphtheria
Whooping cough
Tetanus
Poliomyelitis
Tuberculosis (BCG)
Hepatitis A
Hepatitis B
G E N E R A L I M P R E S S I O N
The undersigned doctor certifies that the general state of health, physical and mental condition of the applicant are excellent, that he/she
is not a carrier of any infectious disease and has no physical disability. The applicant can therefore comply, without risk, with the strict
requirements of professional training in the hospitality industry. The undersigned doctor also certifies that the candidate is not obliged
to follow a special diet.
Date
Doctor’s signature and stamp

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