Client personal details Client identity details

Family name: ROCHA PULIDO Identity document presented: Original Passport

Given names: LUCY MARCELA Identity document number: AY253025
Gender: FEMALE Issuing country: COLOMBIA
Date of birth: 28 Nov 2002 Date of issue: 27 Jan 2022
Country of birth: COLOMBIA Date of expiry: 27 Jan 2032
Source: Australia

Client visa details

Visa: TU 500 Student
TRN: EGP1DYST63
Visa Request ID: 1530679831

Medical History

History or informed of:

Tuberculosis (TB), treatment for tuberculosis? -

Close household contact with Tuberculosis (TB)? -
Prolonged medical treatment and/or repeated hospital admissions for any reason, including a -
major operation or psychiatric illness
Psychological/Psychiatric Disorder (including major depression, bipolar disorder or -
schizophrenia)
An abnormal or reactive HIV blood test -
An abnormal or reactive Hepatitis B or Hepatitis C blood test? -
Hepatitis B -
Hepatitis C -
Cancer or Malignancy in the last 5 years -
Diabetes -
Heart condition including coronary disease, hypertension, valve or congenital disease -
Blood condition (including thalassemia) -
Kidney or Bladder Disease -
An ongoing physical or intellectual disability affecting your current or future ability to function -
independently or be able to work full-time (including autism or developmental delay)
An addiction to drugs or alcohol -
Are you taking any prescribed pills or medication (excluding oral contraceptives, over-the -
counter medication and natural supplements)? Please list
Are you pregnant? -

Client declaration

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Doctor declaration
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