base line health assessment for printed

8/10/2019 Base Line Health Assessment for Printed

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No Have you ever had or needed: No Yes please detail below

1 Illness or Injury requiring hospitalization or surgical intervention?

2

Tuberculosis or treatment for tuberculosis or an abnormal chest x-ray or chronic

cough or bloody cough or a close contact with a person with TB?

3

An infectious or communicable disease lasting more than 2 weeks such as

jaundice, hepatitis, HIV-AIDS etc?

4 Eyes or ears problems such as difficulty hearing or seeing etc?

5 Neurological disease such as seizures, epilepsy, stroke, etc?

6

Nervous or anxiety or depression or mental illness such as autism, mental

retardation etc?

7 Cardiovascular disease such as high blood pressure, heart disease etc?

8 Blood or Hematologic disorder such as anemia or thalasemia etc?

9 Asthma or shortness of breath or chronic cough or other lungs disease?

10

Stomach or digestion problem or liver disorder or bowel disease or other

abdominal symptoms such as heart burn, indigestion, chronic diarrhea, blood in

stool etc?

11 Kidney or bladder disease or prostate problem?

12 Diabetes or other endocrine disorder?

13 Muscle, joint and bone problems?14 Cancer or tumor?

15 Sexual transmitted disease?

16 Tattoo or body piercing or history of blood transfusion?

17 Skin disorder?

18 Reproductive or genital disorder?

19

Any other illness, injury or medical condition more than 2 weeks or recurring

condition not previously mentioned? Any loss of weight in last 6 months?

20 History of family disease such as dialysis, cancer, coronary heart disease etc?

No Additional Medical Information

1

Are you taking medications? (name of medicines, dosage, length of consumption

etc)

2 Do you have any drug, food or other things allergies?

3 History of torture or violence

4 How many months have you displaced from home?

5 Habits/ history of habits/ drug abuse:

Alcohol (how many years/ when, how much units per week etc)

Smoking (how many years/ when, how many pieces per day etc)

Name of drugs (how many years/ when, dosage, any treatment etc)

6 Immunization History

BCG

DPT

Polio

Measles

DT

TT

Hepatitis B

Other:

I hereby declare and certify that the information I have provided on this form is

true and complete (correct)

Migrant's Signature (over 16 years old age and relationship) or Finger Print and

name Date

MEDICAL HISTORY

For Female only

Are you pregnant? What is the expected date of birth? How is the history of previous

pregnant?



yes/ no

yes/ no

1 Date of Examination

2 BMI (weight-KG/ height-M2)

Weight (KG)Height (cm)

Waist circumference (cm, >=20 years old

age)

3

Head Circumference (cm, <18 months old

age)

Left Mid Arm Circumference (abnormal

BMI, cm)

4 Visual Acuity right left

Uncorrected

Corrected

Pin Hole

Ishihara Test

5Blood Pressure ( >=11 years old age, initial,repeated, mmHg)

Pulse Rate and Rhytm

Respiratory Rate and type of respiratory

Temperature (per indication)

normal abnormal

6

General Appearance (including visible

disability, anemia and jaundice)

7 Mental, Cognitive and Intelligence Status

8Developmental milestones (< 5 years oldage)

9 Eyes (including funduscopy)

10

Ears (including hearing), Nose and Mouth

(including throat and teeth)

11 Skin, Lymph Nodes and Breast

12 Cardiovascular System

13 Respiratory System

14 Gastrointestinal System

(including hernia, rectal, liver and spleen)

15 Endocrine System

16

Genito-Urinary System (including prostate

exam if needed)

17 Musculo-skeletal System

18 Neurological System

19 Extremity

20 Pregnant

Physician's signature and name Date:

PHYSICAL EXAMINATION

Was a chaperone present during the examination? (name and relationship)

Was an interpreter present during the examination? (name and relationship)

please specify if abnormal

Yes/ No

please specify if abnormal or pregnant

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