Scribd
Upload
388 views1 page

Medical Examination Form

MEDICAL EXAMINATION OF VISA APPLICANT At the request of the Embassy of the Republic of the Philippines.

Uploaded by

Eric Zarriello
Copyright
© © All Rights Reserved
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
388 views1 page

Medical Examination Form

MEDICAL EXAMINATION OF VISA APPLICANT At the request of the Embassy of the Republic of the Philippines.

Uploaded by

Eric Zarriello
Copyright
© © All Rights Reserved
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
You are on page 1/ 1

FA Form No.

11(REVISED 2016) Applicant's recent


picture, front view,
without glasses
EMBASSY OF THE REPUBLIC OF THE PHILIPPINES (passport size)
Oslo Do not attach
Visiting Address: Nedre Vollgate 4, 0158 Oslo, Norway scanned pictures.
www.philembassy.no
Signature on front
of picture

MEDICAL EXAMINATION OF VISA APPLICANT


At the request of the Embassy of the Republic of the Philippines, Oslo, NORWAY
Please fill in the blanks completely and correctly and all entries must be in CAPITAL LETTERS. This form should be filled out in duplicate, the original
to be given to the applicant and the duplicate copy to be filed at the Consulate.

Place _________________________________ Date of Examination


(Hospital/Clinic/Institution)
Address:
I certify that the above date I examined
NAME: _______________________________________________________________
Last Name First Name Middle Name
AGE: GENDER  Male  Female CITIZENSHIP:
And that under the Philippine Immigration Regulations the applicant should be classified as follows:
(Encircle the appropriate class)

CLASS A DANGEROUS CONTAGIOUS DISEASE


Chancroid, Gonorrhea, Grenolome Inguinate, Leprosy (Infectiuos) Lympho-Granuloms
Venereum, Syphilis (Infectious Stage), Tuberculosis (Active), and AIDS *
SERIOUS MENTAL DISORDERS
Mental retardation (mental deficiency), Insanity, Previous occurrence of one or more
Attacks of insanity, Antisocial personality, Mental defects, Epilepsy, Sexual deviation,
Narcotic drug addiction, Chronic Alcoholism
CLASS B IF NOT CLASS A
Person having physical defect, disease or disability serious in degree or permanently
in nature that will impair their ability to earn a living as to make them likely to be a
public charge.
CLASS C Minor Conditions
MEDICAL RECORDS
1. Pertinent medical history:
2. Significant physical examination:
3. Chest X-ray report: (for ages 4 yrs. and above)
(negative, standard size, or in CD (preferable), to be presented to the Embassy and hand carried to the Philippines.)
4. Laboratory Examination: (Attach laboratory reports)
i. Blood serology : (Ages 15 years and above)
ii. Urine : (Ages 1 year and above)
iii. Stool : (Ages 1 year and above)
5. Not physically and mentally defective or diseased
Examining Physician Address
__________________________________________
__________________________________________
Signature __________________________________________

_____________________________________________________ __________________________________________
Full Printed Name

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy