Nationwide Health Systems CHILD / EDE / APPT

BAGUIO, Inc DATE:___________________ PWD / SENIOR / XSD : _________

Referred by:
a. Self (family/friend/internet) c. Immigration consultant IME/ UMI/ HAP/ NZER: ____________________________
b. Embassy information d. Company / Recruiter
PLEASE FILL UP DOTTED BOXED AREA ONLY NEW MED / REMEDICAL:INTENDED
______________
LENGTH O
PREFERRED PHILIPPINE CONTACT NUMBERS AND ADDRESS: CLIENT INFORMATION:

Cellphone: ____________________________/_____________________________ Last Name: _______________________________________

Email Address: ______________________________________________________ First Name:_______________________________________
Address: ____________________________________________________________ Middle Name: ____________________________________
__________________________________________________________ Age: __________ Gender: _________ Civil Status: ______________
expire in 6 months?
Passport Number: ________________________________ (YES/NO) Date of Birth: Day / Month / Year
If applicable
Other ID: _____________________________________________ Last Menstrual Period: Date Started / Date Ended

Intended Occupation / Activity / Study (Course): ______________________________________________________________________________________

a. Is this your or your family's first visa related medical examination? Please encircle YES NO
b. Has your or your family's application for a visa ever rejected before? Please encircle YES NO
c. NEW ZEALAND APPLICANTS INTENDED LENGTH OF STAY? Please encircle Less than 6 mos / 6 - 12 mos / 12 - 24 mos / more than 24 mos
I. RESIDENCE ( Skilled - Business / Pacific Categories / Family / Humanitarian UNHCR / Humanitarian - other)
VISA CATEGORY
II. TEMPORARY ( Visitor / Student / Work with job offer / Work without job offer)
Please encircle
III. WORK TO RESIDENCE ( Worker / Family Worker )
d. CANADA APPLICANTS Did you receive a letter that your application is under review based on the new public
policy effective 1 June 2018? Please encircle
YES NO
if UPFRONT MEDICAL, what is your VISA CATEGORY? Please encircle VISITOR STUDENT WORKER (Express Entry) Attach
recent
e. AUSTRALIA APPLICANTS If you are applying for a Temporary visa, do you intend to apply for a permanent stay
in Australia with in the next 6 -12 months? Please encircle YES NO Photo
Would you like your health to be assessed “upfront” for a permanent stay in Australia? Please encircle YES NO
Do you intend to work or study to be a Nurse / Physician / Dentist / Paramedics? Please encircle YES NO
DECLARATION BY EXAMINEE (OR PARENT GUARDIAN IF UNDER 16 YRS OF AGE)

I declare that the information given above are TRUE and CORRECT. ________________________________________________________
Print Name and Sign (Examinee or Accompanying Parent/Guardian if 16 yrs old and below)
Father / Mother / Grandmother / Grandfather / Uncle / Aunt / Guardian / Brother / Sister
FOR NHSBI STAFF ONLY
TIME IN TIME OUT INITIAL
CPE, Urinalysis, RPR, HIV, Hbsag, Anti-Hcv, FCBC, HBA1C, eGFR, CXR
INITIAL INTERVIEW:
CPE, Urinalysis, RPR, HIV, Hbsag, full CBC, Crea, LFT, CXR
CONSENT:
CPE, Urinalysis, HIV, Hbsag, Anti-HCV, CXR
SCAN/PICTURE:
CPE, Urinalysis, RPR, HIV, CREA, CXR
CPE, Urinalysis, HIV, CXR PRE-EXAM:
CPE, Urinalysis, CXR OTHER TESTS CASHIER: CASH/ADV DEPOSIT
UA-Dipstick IGRA
CPE, Urinalysis RECEIPT/LOGBOOK
UA-Microscopy CALCIUM
CPE Only PREG TEST HBeAG LABORATORY: URINALYSIS
NHSBI METRO HIV HBV - DNA BLOOD TEST
HBSAG Liver Fibro Scan DOH
ANTI-HCV ECG
FBS CHEST UTZ ADD'L TEST
To tal M edical
To tal Cash P aid
LIPID PROFILE LGBP UTZ
Fee S. CREA CXR - PA
CHEST X-RAY: PA VIEW
Signature Change BUA CXR - APL
AFP CXR - APICO ADD'L VIEW
A dd'l Fee A dd'l Fee LFT CXR - R LAT
A dd'l Fee A dd'l Fee SGPT CXR - L LAT
HEIGHT AND WEIGHT:
FCBC CXR - LOR
To tal A dd'l Fee To tal Cash P aid
EGFR CXR - R OBL PHYSICAL EXAM:
Signature Change TPPA CXR - L OBL REFERRAL:
UPC CXR - SPOT
TOTAL MEDICAL FEE PAID
FERRITIN

FINAL INTERVIEW: WAITING AREA

(2ND FLOOR EXTENSION AREA)

Pertinent Laboratory Findings: circle/highlight/add required tests (MARK "N" for NORMAL RESULTS)
_UA_ RPR _HIV HBSAG ANTI-HCV _CXR_ EGFR FCBC HAIC RPT UA CREA _ECG_ LFT_ LGBP FBS_ FLIPID _____ ______ __ ___ ______

Blood Pressure Body Temp: _________________ Uncorrected / Corrected PH

Initial: _____/_______ BMI: _______________________ Height in cm: __________ OS/L _________/___________ GLASSES
CONTACT LENS
Repeat: _____/_______ Head Circumference: _________ Weight in kg:__________ OD/R__________/___________
PERTINENT HISTORY OR PHYSICAL EXAMINATION: Recommendations/Comments/Notes
GRADING
A B
MD: _________________

SUBMITTED: _____________

2019