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CONFIDENTIAL ENTRY MEDICAL EXAMINATION UNITED NATIONS AND SPECIALIZED AGENCIES
       I hereby authorize any of the doctors, hospitals or clinics mentioned in this form to provide the United Nations Medical Service with copies of all my medical records so that the Organization can take action upon my application for employment.

       I certify that the statements made by me in answer to the questions below are, to the best of my knowledge, true, complete and correct. I realize that any incorrect statement or material omission in the medical information form or in any other document required by the Organization renders a staff member liable to termination or dismissal.

       Date:(dd/mm/yy).................................................        Signature: .....................................................................
Pages 1 and 2 are to be completed by the candidate
FAMILY NAME (IN BLOCK CAPITALS)
GIVEN NAMES
MAIDEN NAME (FOR WOMEN ONLY)
 SEX
      O  M              O  F
ADDRESS (STREET, TOWN, DISTRICT OR PROVINCE, COUNTRY) DATE OF BIRTH:
NATIONALITY:
POSITION APPLIED FOR (DESCRIBE NATURE OF WORK) TELEPHONE:............................BIRTHPLACE........................................
DUTY STATION PRESENT MARITAL STATUS          Single       O

Married      O Date:(d/m/y).................. Divorced  O Date:(d/m/y)...............

Separated  O Date:(d/m/y).................. Widowed O Date:(d/m/y)................
Have you ever undergone a medical examination for the United Nations or one of its agencies?.....................................
Have you ever been employed by the United Nations or one of its agencies?................................................................
If so, please state when, where and for which Organization:.........................................................................................
FAMILY HISTORY
Relative
Age
(if still alive)
State of Health
 (If still alive, present state; 
  if deceased, cause of death)
Age
at death
Have members of your family had
the following illnesses or disorders?
YES
NO
WHO?
FATHER . . . High Blood Pressure . . .
MOTHER . . . Heart Disease . . .
BROTHERS . . . Diabetes . . .
SISTERS . . . Tuberculosis . . .
SPOUSE . . . Asthma . . .
CHILDREN . . . Cancer . . .
. . . . Epilepsy . . .
. . . . Mental Disorders . . .
. . . . Paralysis . . .
TO BE COMPLETED BY THE OFFICIAL REQUESTING THE MEDICAL EXAMINATION TO BE COMPLETED BY THE DIRECTOR 
 OF THE MEDICAL SERVICE
Name of Official:............................................................................................
Department or Unit:......................................................................................
Date:		 Medical Classification:   O  1a    O  1b   O  2a    O  2b
Comments: ....................................................................................................
DATE: (d/m/y)                    Signature:
VERY IMPORTANT: Please indicate the recruiting Agency or Organization:
Each question requires a specific answer (yes, no, date, etc.); to leave a blank or draw a line is not sufficient. If the questionnaire is not fully completed and enquiries are therefore needed, time may be lost. 
1.     Have you suffered from any of the following diseases or disorders? Check yes or no. If yes, state the year. 
 .
YES
Date
NO
  .
YES 
Date
NO
  .
YES 
Date
NO
  .
YES
Date
NO
Frequent sore throats
  .  .
Heart and blood vessel disease
  .  .
Urinary disorder
  .  .
Fainting spells
  .  .
Hay fever
  .  .
Pains in the heart region
  .  .
Kidney trouble
  .  .
Epilepsy
  .  .
Asthma
  .  .
Varicose veins
  .  .
Kidney stones
  .  .
Diabetes
  .  .
Tuberculosis
  .  .
Frequent indigestion
  .  .
Back pain
  .  .
Gonorrhoea
  .  .
Pneumonia
  .  .
Ulcer of stomach or duodenum
  .  .
Joint problems
  .  .
Any other sexually 
 transmitted disease
  .  .
Pleurisy
  .  .
Jaundice
  .  .
Skin disease
  .  .
Tropical diseases
  .  .
Repeated bronchitis
  .  .
Gall stones
  .  .
Sleeplessness
  .  .
Amoebic dysentery
  .  .
Rheumatic fever
 . .
Hernia
 . .
Any nervous or mental disorder
  .  .
Malaria
  .  .
High blood presure
  . . 
Haemorrhoides
  . . 
Frequent  headaches
 . . . .
2.     Are you being treated for any condition now?.............  Describe: ......................................................................................................................................................
3.     Have you ever coughed up blood?.................................................................................................................................................................................................
4.     Have you ever noticed blood in your stools? ..............In your urine?................Give details:................................................................................................................
5.     Have you ever been hospitalized (hospital, clinic, etc.)? ...................................................................................................................................................................
       Why, where and when?................................................................................................................................................................................................................
6.     Have you ever been absent from work for longer than one month through illness?.........If so, when?.........................................................................................................
7.     Have you had any accidents as a result of which you are partially disabled?............ If so, what and when?.................................................................................................
        Do you have any other disability?.................................................................................................................................................................................................
8.     Have you ever consulted a neurologist, a psychiatrist or a psychoanalyst?.............................................................................................................................................
        If so, please give his/her name and address:.....................................................................................................................................................................................
        For what reason?..........................................................................Date of consultation:(d/m/y) ........................................................................................................
9.     Are you taking any medicine regularly?...............If so, which?...........................................................................................................................................................
10. Have you gained or lost weight during the last three years?....................If so, how much?........................................................................................................................
11. Have you ever been refused life insurance?.............If so, state reason:.....................................................................................................................................................
12. Have you ever been refused employment on health grounds?..............If so, state reason:............................................................................................................................
13. Have you ever received or applied for a pension or compensation for any permanent disability?.........Degree?................................................................................................
      Please give details:........................................................................................................................................................................................................................
14. Have you ever stayed in a tropical country?...............If so, for how long?..............................................................................................................................................
15. Have you in the past suffered from any condition which prevented travel by air?........................................................................................................................................
16. Do you consider yourself to be in good health?..............Do you have full work capacity?.........................................................................................................................
17. Do you smoke regularly?    O Yes    O No                If so, what do you smoke?   O Cigarettes  O Pipe    O  Cigars
      For how many years have you smoked?...................How much per day?.............................................................................................................................................
18. Daily consumption of alcoholic beverages:.........................................................................................................................................................................................
19. Has any doctor or dentist advised you to undergo medical or surgical treatment in the foreseeable future?......................................................................................................
      Give details:................................................................................................................................................................................................................................
20. Give any other significant information concerning your health:..............................................................................................................................................................
21. What is your occupation?...................................................Indicate at least three posts you have occupied:.............................................................................................
      .................................................................................................................................................................................................................................................
22. List any occupational or other hazards to which you have been exposed:..................................................................................................................................................
23. Have you been rejected for military service for medical reasons?.............................................................................................................................................................
24.   FOR WOMEN         Are your periods regular?     O  Yes   O  No                           I       Do you take contraceptive pills?   O  Yes   O  No       If so, for
                                           Are they painful?           O  Yes   O  No                           I       how many years have you been doing so?...........Have you ever
        Do you have to stay in bed when they come?        O  Yes   O  No                            I      been treated for a gynaecological complaint?   O   Yes   O    No
        If so, for how long?........................................Date of your last period:..........................If so, which?................................................................................................
TO BE COMPLETED BY THE EXAMINING PHYSICIAN
    GENERAL APPEARANCE                                                Height: cm..................Weight: kg.............................................................................................................
    Skin:.....................................................................................Scalp:...............................................................................................................................................
    SIGHT, MEASURED VISUAL ACUITY
    Gross vision  :               Right..................... Left...........................Pupils: Equal?...........................Regular?.........................................................................................
    Vision with spectacles :  Right.....................  Left...........................Fundi (if necessary):...........................................................................................................................
    Near vision  :                Right.................... . Left..........................Colour vision:.................................................................................................................................
    With correction  :          Right.....................  Left...........................
    HEARING  I  Right :    Normal :...................... Sufficient:.......................................Insufficient:............................................................................................................
    (test by        I  Left :      Normal :......................Sufficient:.......................................Insufficient:...........................................................................................................
    whispering)  I  Ear drum:Right :.........................Left:..............................................
    NOSE-MOUTH-NECK   Nose    :.................Pharynx :.......................................Teeth :......................................................................................................................
    Tongue :.................Tonsils :.........................................Thyroid :....................................................................................................................................................
    CARDIOVASCULAR SYSTEM                                             Peripheral arteries
    Pulse rate  :....................................Auscultation : ..........................-carotid :....................................................................................................................................
    Rhythm     :...................................Blood pressure :.......................- posterior tibial :..........................................................................................................................
    Apex beat  :...................................Varicose veins :........................- dorsalis pedes :............................................................................................................................
    Electrocardiogram...........................................................................Please attach tracing
    RESPIRATORY SYSTEM                                                       I   Breasts
    Thorax:..................................................................................I   ...................................................................................................................................................
    DIGESTIVE SYSTEM                                                                 Spleen:           ..............................................................................................................................
    Abdomen :............................................................................      Hernia:            .............................................................................................................................
    Liver :..................................................................................      Rectal examination:........................................................................................................................
    NERVOUS SYSTEM                                                                   Plantar reflexes :.............................................................................................................................
                                      - To light:..........................................       Motor functions :............................................................................................................................
    Papillary reflexes:........-  On accommodation:............................       Sensory functions :..........................................................................................................................
    Patellar reflexes :...................................................................       Muscular tonus :.............................................................................................................................
    Achilles reflexes:...................................................................       Romberg's sign :.............................................................................................................................
    MENTAL STATE
    Appearance:..........................................................................       Behaviour:....................................................................................................................................
    GENITO-URINARY SYSTEM
    Kidneys:..............................................................................      Genitals:........................................................................................................................................
    SKELETAL SYSTEM
    Skull :.................................................................................     Upper extremities:.............................................................................................................................
    Spine:..................................................................................     Lower extremities:............................................................................................................................
    LYMPHATIC SYSTEM
   CHEST X-RAY (Full size film - Please send the radiologist's report).
   LABORATORY
   The results of all the following investigations must be included except where marked "if indicated".
   Except by prior agreement, only the investigations mentioned are done at the Organization's expense.
   Urine : Albumin..........................................Sugar.........................................Microscopic..............................................................................................................
   Blood:  Haemoglobin  :................................%..............................Grams/1     Leucocytes :..............................................................................................................
   Haematocrit     :..........................................%...............................................Differential count (if indicated):.....................................................................................
   Erythrocytes    :...........................................                               Blood sedimentation rate:.............................................
   Blood chemistry
                           Sugar         :..............................................        Urea or creatinine:.......................................................
                           Cholesterol :..............................................        Uric acid             :.......................................................

    Serological test for syphilis:   Please attach laboratory report
    Stool examination (if indicated):
    COMMENTS (Please comment on all the positive answers given by the candidate and summarize the abnormal findings)
 
 

 
    CONCLUSIONS (Please state your opinion on the physical and mental health of the candidate and fitness for the proposed post)
 
 
 
 

 
    The examining doctor is requested before sending this report to verify that the questionnaire, pages 1 and 2 of this form, has been fully completed by the candidate and that all the results of the investigations required are given on the report. Incomplete reports are a major source of delay in recruitment.
    Name of the examining physician (in block capitals):
.......................................................................................................................
   Address:
..........................................................................................		    Signature:.....................................................................................................

  DATE: (d/m/y)......................................................................