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malik.altwoity1
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57 views2 pages

214214

Uploaded by

malik.altwoity1
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Se BA HB He Be BE Re fees PHYSICAL EXAMINATION FORM st | 27 Male aver |Y/ 12 | [nee (ee fit fede | S| arene | ty |i g9g SEN at Present mailing address Fare DX Y em a ese Far LS A - Nationality Birth Blood type (or Area) place | Yemen ULE A A PA: (UL “A Have you ever had any of the following as (Gach item must be answered “Yes” or No”) a HES R_—Typhus fever Cyes —i——9H]_—_Bacillary dysentery SSR if JURE — Poliomyelitis ae Oves AGH Brucellosis No OYes MR Diphtheria yp Yes TEHLFE Viral hepatitis jo Ces 2 A Scarlet fever No P*WAUEER — Puerperal streptococcus infection YH #4 Relapsing fever No oie a oR (No Yes ROR Hi Typhoid and paratyphoid fever oo EFHEMETEOUBLA, Epidemic cerebrospinal meningitis ZNo OYes ATMA FUE BUSS ANE EERE: (HEU AE AG” we HE” Do you have any of the following diseases or disorders endangering the public order and security’ (Each item must be answered “Yes” or “No”) Ro Toxicomani: iA Mental confusion 0 fates m HHMI Poychosis: BRIE Manic paychosis “Sof CRepuiic OF Yd en SHUN Paranoid psychosis ‘4)%3 — Hallucinator Gnas Sey of tes of Forehyn Atars a BOK | oe “a | am Bk Ake z sig (ZD—eM | Wet VY Ke | lod pressure no TH ERR ah ai [Tmo Sif ana Soh a east Development Uo V1 Nourishment /V OV Nec Ve “ayn we AL go | BRIER L_— Vision AR_£/A Corrected vision #7 R_—— sake, aD ak Colour sense VOY skin Mov — aay i vi eer) oA wor met ete fT yessgaet Sh 2 z < teen Me mh Langs oY re, Abdomen TOME ee WERK ate pov vl) Extremities qa Nervous | Spine SEITE None Other abnormal findings De ae X aA ECC teers (thease) Nev ver ee Chest X-ray exam (attached chest X-ray report) eee (fad SL ‘Ae GUM) Vor rg Laboratory exam (attached test report of Reevonaiie Fotos AIDS. Syphilis etc) None of the following diseases of disorders found during the al Cholera Joe ag BONNE Yellow fever love MSH Lung tuberculosis jo WE fH — Plague ore ae AIDS one IRI Leprosy NONE KEHST —Psychosis. yy on B ete La Suggestion Official Stany Fit dee ssudle{ing,, ; cones dries Or. . witeeal i (j

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