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NEW Med Report

This document is a medical certificate from the Department of Home Affairs in the Republic of South Africa. It certifies that a medical officer examined a number of individuals and found them to be in generally good health, not suffering from any contagious conditions, and not mentally disordered or physically defective. The certificate requests details of any recurrent diseases, conditions, or defects that the individuals have suffered from as well as the seriousness and any treatment prescribed. Space is provided to list details for each individual examined.

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170 views

NEW Med Report

This document is a medical certificate from the Department of Home Affairs in the Republic of South Africa. It certifies that a medical officer examined a number of individuals and found them to be in generally good health, not suffering from any contagious conditions, and not mentally disordered or physically defective. The certificate requests details of any recurrent diseases, conditions, or defects that the individuals have suffered from as well as the seriousness and any treatment prescribed. Space is provided to list details for each individual examined.

Uploaded by

megan.hoover2722
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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G.P.-S.

017-0194 BI-811

DEPARTMENT: HOME AFFAIRS


REPUBLIC OF SOUTH AFRICA

MEDICAL CERTIFICATE

CONDITIONS OF A RECURRENT NATURE


Although the person(s) may be generally in a good state of health at the time of the examination, it would
be appreciated if the medical officer / practitioner could furnish details of any disease, condition or defect
the person(s) has / have suffered and which might recur.

I hereby certify that I have examined the following person(s):

1. ........................................................................... 5. .............................................................................

2. ........................................................................... 6. .............................................................................

3. ........................................................................... 7. .............................................................................

4. ........................................................................... 8. .............................................................................
and find him / her / them—
(a) not mentally disordered* or physically defective in any way;
(b) not suffering from leprosy, veneral disease, trachoma, or other infections or contagious
(b condition;
(c) generally in a good state of health;
except for the following defects observed:
(Please type or print)
Name of person(s) Details regarding the disorder, disease or disability, the seriousness thereof and
the treatment, if any, prescribed/recommended

............................................................. ...............................................................................................................

............................................................. ...............................................................................................................

............................................................. ...............................................................................................................

............................................................. ...............................................................................................................

............................................................. ...............................................................................................................

............................................................. ...............................................................................................................

Official stamp and address of medical officer/


practitioner/hospital

................................................................ ...........................................................................................
Signature of medical officer / practitioner
...........................................................................................

Date ........................................................ ...........................................................................................

Int. code * “Mentally disordered” includes the following:


290–299 All psychoses.
300 Neuroses.
301 Personality disorders.
303–304 Addictions.
308 Behaviour disturbances of childhood.
310–315 All forms of mental retardation.
320–349 Epilepsy and all other forms of degeneration of the central nervous system.

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