UBOe.._ Medical Report AuPair wemetere Tobe completed by your Doctor - Relatives may not complete this report trent Au Parin America, the applicant willbe ving for an extended period of time in the home ofa family with young children tis {hetefore important that we ae advised of any physical, mental or emotional healt problems or family history Isues which may have an impact on the applicant's abilty to cary out their duties appropriately Please note that withholding or falsifying any information ‘may result in the applicant being withdrawn from the program. Dovouhave acess tothe patients fullmedical history? X Yes C1No Hawlong have youknown the patient? yk Vai ‘What date wos the patient's last medical appointment? 2S _/ Unknown What was the reason? (please tick below) YX Annual vit Minor medical concern/iness () Chronic covdition Other (please describe) ‘Tick the appropriate box If there are any abnormalities to the following systems: O Eats, nose and throat D eyes Cl Neuropsychiatric Respiratory system/lungs 1D Genitourinary O skin D cardiovascular O Musculoskeletal O Brain, nervous system O Gastrointestinal CO Metabolic 0 other {ithe applicant, tothe best of your knowledge alikely carrier of any infectious disease, such as Hepatitis B or €, or the HIV nua? (The applicant does not need to be tested) Over X No ‘ave you noticed any changes in weight or eating habit of the applicant that may indicate an eating disorder? Yes No Has the applicant ever been hospitalised or had surgery, including cosmetic surgery? D Yes & No Une gnpicant curently or has the applicant ever been teated/counselled o received medication fora nervous condition, eating disorder, depression or emational problem? O Yes’ Kj No Have you any knowledge that the applicant has ever been a victim of physica, emotional or sexual abuse? O Yes & No EINETE ay history of nervous or emotional problems, depression or abuse (sexual, emotional or physical) inthe applicant's family background? O ves K No "You have answered ‘yes' to any ofthe above, please provide detalls including dates treatment and medication required: raps use this space to comment on the aplicants current ematianal wellbeing and provide anyother relevant informations Applicants wewta) Weal i excellent axl han yo verlsition ta tare ane of otters, fiter having reviewed the applicant's medical notes, please give your opinion on the applicants general state of health MW Excellent O Good O Fair O Poor Name of Doctor Audae’s Felipe Pues Please add your Doctor's or Medical Practice stamp below Address Calle M3 a 49-58) Goactcl, Colousbia ae Se Rei Coleen Dt Andrés Fetpe Pineda Vanegas Médico General ———————————EXZ Universidad dea Sabana Telephone CE. 1072709081, ES SS have examined [f and/or reviewed medical notes of Bl (Tick f applicable) the above named applicant and | find them to be capable ‘of benefitting from and fully participating in an Au Pair in America program. ves fno, did you fully understand all the questions asked on this form? O Yes O No vate: _ Septeuiley 23) 2093 ‘Au Pair in America, 37 Queen's Gate, London, SW? SHR August 2021 Do you speak English? Doctor's Signature: Powered by CamScannerUPDF San Vaccination Record AuPair Itisan Au Pair in America program requirement for th 3 applicant to be immunized against certain diseases. Please provide the ‘vaccination history for this applicant below. Please confirm the applicants immunized against the following: Tetanus X ves oxte 200: Measles X Yes ate 2 Mumps Ki Yes oate Rubella (German Measles) Aves Date Scpbewbe( 2003 Tuberculosis ‘This is mandatory for applicants from Brazil, China, South Africa, Russia and Thailand, Highly recommended for applicants from other countries, Mantouxtest OR Dyes vate X.No Result: (] Positive OD Negative Chest x Ray O Yes bate K No Result: [1 clear 1 Not clear ositve test results (unless the applicant was immunized against TB) will require a copy ofa recent chest x-ray ‘The following immunizations are highly recommended but not required: Fu vaccine ves. vate ee Small Pox O ves ate aoe Typhoid ves vate B no Hepatitis 8 Yes vate Mach AFH no Diphtheria B Yes oate 260° No Poko K res ose plete’ 2503 One Meningitis. O ves . one CucerorHrotreionysuteestom Te, ome Damages as © 8° ‘Whooping Cough If the applicant is placed with a Host Family that requires the care of a baby under the age of 6 months, be immunized against Whooping Cough, P. lease confirm ifthe applicants immunized: ‘Whooping Cough ves date Seplaubey 2003 No covid-19 the applicant will be required to Has the applicant been vaccinated against Covi 382 Wves-fistdose vate Avast 23/2004 Yes-second dove ate Nowuber 2/224 0 no Please specify which vaccination they received: _PFizor Name of Doctor Aus eda \laue. Please add your Doctors or Medical Practice stamp below Address Calle W. = 33 Te OO Telephone 20. oyou speak English? fl] ves Doctor's Signature: Pair in America, 37 Queen's Gate, London, SW7 SHR August 2022, Powered by CamScanner