IMMIGRATION MEDICAL

TITLE
SURNAME
NAME / S
GENDER

PLEASE COMPLETE WHICHEVER IS APPLICABLE.

THIS IS THE NUMBER THAT YOU WOULD HAVE RECEIVED FROM THE CIC WHEN LODGING YOUR APPLICATION
IME NUMBER ?
UCI NUMBER ?
UMI NUMBER ?

POSTAL ADDRESS

PHYSICAL ADDRESS

TEL NUMBER
CEL NUMBER
EMAIL

DATE OF BIRTH
CURRENT AGE
ID NUMBER
COUNTRY OF BIRTH
PASSPORT COUNTRY OF ISSUE
PASSPORT NUMBER
PASSPORT ISSUE DATE
PASSPORT EXPIRY DATE

YE IF YES, PLEASE PROVIDE

MEDICAL HISTORY NO
S DETAILS
Have you ever been diagnosed with
Tuberculosis (TB)? Have you ever had to take
treatment for Tuberculosis (TB)?
Have you ever been in close contact at work
or at home with a person known to have
Tuberculosis (TB)?
Have you ever been admitted to hospital and /
or received medical treatment for an extended
period for any reason (including for a major
operation or treatment of a psychiatric illness)?
Do you suffer, or have you ever suffered, from
mental health problems?
Have you ever been told you are HIV positive?
Do you have, or have you ever had, hepatitis,
problems with your liver or yellowing of the
skin?
Do you have or have you had cancer in the
last 5 years?
Do you have high blood sugar / diabetes?
Do you have heart problems, including high
blood pressure or a heart condition that you
were born with?
Do you have a blood condition?
 IMMIGRATION MEDICAL

Do you have bladder or kidney problems?

MEDICAL HISTORY (continued) NO YES IF YES, PLEASE PROVIDE DETAILS

Do you have a physical or intellectual disability that make it
difficult for you to function independently (for example, to
move around or learn) or work full-time?
Do you need to take drugs or drink alcohol regularly?
Are you pregnant ?
To note, the medical may continue -
If you are pregnant, do you want to continue the process, however without an x-ray, the medical
noting that an x-ray is needed. cannot be completed, and will be set aside
until such time an x-ray is provided.

Are you taking any prescribed pills or medication (excluding

oral contraceptives, over-the counter medication and natural
supplements)? If yes, please list these.

YES (if yes please state Name and

Relationship)

NAME : Ilze
Do you require a Chaperone to be present?
RELATIONSHIP : Mother

NO Not required

English

To note the Consultation, all documentation

and communication will be in English. I will require the service of a translator
and will make the necessary
arrangements for this service

General Supporting Comments :

IMMIGRATION MEDICAL