Professional legal forms

Wapda medical form WANDA TEACHING HOSPITAL COMPLEX 2 Colored Photographs 210Ferozepur Road, Lahore. MEDICAL REGISTRATION From A Form No. New Registration Change Version. 2 Revised On.15032011 1. Company / Department

Football medical form Ex mouth Rugby Football Club Medical Consent Form This form need to be completed by all Parents / Guardians of players Under 18. Players Full Name: Date of Birth: Parent / Guardians Name: Mobile:

Mpa medical form MARITIME AND PORT AUTHORITY OF SINGAPORE SHIPPING DIVISION RECORD OF MEDICAL EXAMINATIONS OF SEAFARERPart A to be completed by the Seafarer who is responsible for answering each question accurately.

Free printable medical forms p... Oklahoma Department of Corrections Periodontal Charting 1 PSR Date R2 PSR Date SEXTANT SCORE 123453 PSR Date SEXTANT SCORE 678910111213L SEXTANT SCORE141516DateInitial 1 2 3FACIALMobility 1 2 3RDateLLINGUAL12345678910111213141516DateInitial

Medical form for students First Congregational Church of Santa Cruz, UCC 900 High Street, Santa Cruz CA 95060 (831) 426-2010 www.fccsantacruz.org Emergency Medical Release Form Name Gender Age DOB Address City Zip School Grade

Bsa medical form Bsajamboree. org 304-250-6750 For frequently asked questions about this Annual Health and Medical Record see Scouting Safely online at http //www. Si el madre o tutor. Date/Fecha Participant s signature/Firma del participante Second parent/guardian signature/Firma del otro padre o tutor if required for example CA/si se requiere por ejemplo en CA This Annual Health and Medical Record is valid for 12 calendar months. Annual Health and Medical Record Registro M dico y de Salud Anual Valid for 12 calendar months V lido por 12 meses calendario Policy on Use of the Annual Health and Medical Record Pol tica para el uso del Registro M dico y de Salud Anual In order to provide better care for its members and to assist them in better understanding their own physical capabilities the Boy Scouts of America recommends that everyone who participates in a Scouting event have an annual medical evaluation by a certified and licensed health-care provider a physician MD or DO nurse practitioner or physician assistant. To be better prepared each participant must complete the following before attending any high-adventure base or La participaci n en cualquiera de las bases de aventura extrema de BSA o en cualquier actividad de aventura extrema en terrenos campestres aislados puede ser f sica mental y emocionalmente agotadora. Para estar mejor preparado cada participante debe completar lo siguiente antes de acudir a cualquier base de aventura extrema o de participar en cualquier actividad de aventura extrema en terrenos campestres aislados Fill in parts A and B of the Annual Health and Medical Record. Providing your medical information on this four-part form will help ensure you meet the minimum standards for participation in various activities. Note that unit leaders must always protect the privacy of unit participants by protecting their medical information* A fin de proporcionar una mejor atenci n para sus miembros y para ayudarles a entender mejor sus propias capacidades f sicas Boy Scouts of America recomienda que todos aquellos que participen en un evento Scouting se sometan a un examen m dico anual realizado por un prestador de servicios de salud certificado y con licencia un m dico Doctor en medicina o Doctor en osteopat a enfermera profesional o asistente m dico. Proporcionar su informaci n m dica en este formulario de cuatro partes ayudar a asegurar que usted cumple con los est ndares m nimos de participaci n en varias actividades. Tome en cuenta que los l deres de unidad siempre deben proteger la privacidad de los participantes al salvaguardar su informaci n m dica* Parts A and B are to be completed at least annually by guardian informed consent and release agreement and talent release statement is to be completed by the participant and parents/guardians. Attach a copy of both sides of your insurance card. Part C is the pre-participation physical exam that is required for participants in any event that exceeds 72 consecutive hours for all high-adventure base participants or when the nature of the activity is strenuous and demanding.

Contoh medical form FORMULA PELAYANAN MEDIA / MEDICAL SERVICES FORM Denis Claim (Berg Tanya X) / Claim type (please give X remarks) : Rabat Japan / Outpatient Gigi / Dental Rabat Snap & Pembedahan / Inpatient & Surgical

Medical form for teachers Outdoor School Medical Information Form Valid 2017 For Students & Visiting Teacher (VT) to fill in This information is intended to assist Outdoor School in case of any medical emergency with your

Employee medical form pdf 368. 2450 Fax 216. 368. 8530 healthservice case. edu Health Service Occupational Health Medical History Employee Information students. case. edu/health Name Last First Middle/Maiden Home Address Street City Zip Code Home Telephone Date of Birth Male Female MM/DD/YYYY Position Department Supervisor Campus Telephone Email Address In Emergency Notify Telephone Address Have you ever worked at Case Western Reserve University Has your name changed Yes No Please give previous name Medical History Current physicians or clinics attended Allergy History Medicine/Drugs Foods Insects etc. Medication/Drugs taken regularly Have you had or do you now have Please check all that apply Seizures Bone or joint pain High blood pressure Loss of eye sight Bleeding problems Breathing problems Parkinson s disease Heart disease Arthritis Cancer Amputation Tuberculosis Multiple sclerosis Muscular dystrophies Backache chronic Black out spells Blood clots Neurological problems Disability/Rehabilitation Diabetes Varicose veins Stroke Circulation problems Immune system disease Hepatitis/Jaundice Please list any other medical problems you may have Have you had any of the following Hernia Repair Type Date Orthopedic Surgery Cardiac Surgery Other Surgery Date of Immunization Tetanus booster Rubella Immunization Measles Immunization Rabies Immunization Rabies Titer Have you had Hepatitis B vaccine Do you smoke Do you exercise Approximate Date If yes what If yes How frequently For what length of time Explain Prior Work Environment Have you ever had an On the Job injury If Yes Date Place Carcinogens Asbestos Radio-active materials Radiation producing equipment If YES please indicate where Do you understand all of these questions Case Work Environment What are your duties Will you be Doing any lifting Working with chemicals What kind Working with patients Where Handling experimental animals Picking up biohazard waste for disposal I have completed this form and I certify that the information given is true. University Health Service Division of Student Affairs 10900 Euclid Avenue Cleveland Ohio 44106-4901 Phone 216. 368. 2450 Fax 216. 368. 8530 healthservice case. edu Health Service Occupational Health Medical History Employee Information students. case. edu/health Name Last First Middle/Maiden Home Address Street City Zip Code Home Telephone Date of Birth Male Female MM/DD/YYYY Position Department Supervisor Campus Telephone Email Address In Emergency Notify Telephone Address Have you ever worked at Case Western Reserve University Has your name changed Yes No Please give previous name Medical History Current physicians or clinics attended Allergy History Medicine/Drugs Foods Insects etc* Medication/Drugs taken regularly Have you had or do you now have Please check all that apply Seizures Bone or joint pain High blood pressure Loss of eye sight Bleeding problems Breathing problems Parkinson s disease Heart disease Arthritis Cancer Amputation Tuberculosis Multiple sclerosis Muscular dystrophies Backache chronic Black out spells Blood clots Neurological problems Disability/Rehabilitation Diabetes Varicose veins Stroke Circulation problems Immune system disease Hepatitis/Jaundice Please list any other medical problems you may have Have you had any of the following Hernia Repair Type Date Orthopedic Surgery Cardiac Surgery Other Surgery Date of Immunization Tetanus booster Rubella Immunization Measles Immunization Rabies Immunization Rabies Titer Have you had Hepatitis B vaccine Do you smoke Do you exercise Approximate Date If yes what If yes How frequently For what length of time Explain Prior Work Environment Have you ever had an On the Job injury If Yes Date Place Carcinogens Asbestos Radio-active materials Radiation producing equipment If YES please indicate where Do you understand all of these questions Case Work Environment What are your duties Will you be Doing any lifting Working with chemicals What kind Working with patients Where Handling experimental animals Picking up biohazard waste for disposal I have completed this form and I certify that the information given is true.

Mass rmv immediate threat medi... P.O. Box 55896 Boston, MA 02205-5896 www.mass.gov/massdot/rmv Request for Immediate Threat License Suspension / Revocation Please Mail Immediately or FAX to (857) 368-0013 TO: The Registry of Motor

New patient medical forms pdf NEW PATIENT HISTORY FORM NAME (Last, First, Middle) HOME PHONE AGE WORK PHONE BIRTHDATE OCCUPATION SEX MARITAL STATUS S EMERGENCY CONTACT? S PHONE PREVIOUS PHYSICIAN M W D IF MARRIED, SPOUSE? S NAME

Ntsa medical form FORM A DRIVING SCHOOLS REGISTRATION/ RENEWAL/ VARIATION CHECKLIST PART A. GENERAL INFORMATION Please fill in the necessary information. a) Name of driving school b) Postal address c) d) e) f) g)Physical

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