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#12Physician Examination Form

The Physician Examination Form (www.fusia.net/physicianexam) is completed by a licensed physician/practitioner at least five business days prior to the participant’s arrival in the US and while the program is ongoing upon request by the sponsor. Complete by pen/type. OEM students may submit their school’s physical exam form in place of this form.

Dear Physician/Practitioner,

(name) (gender) (DOB) Email (email) will be undertaking an internship/training program in the US from (start date) to (end date) for (#) weeks. We would appreciate your cooperation in giving the participant a brief examination, answering the following questions based on the participant’s disclosed past medical history, and adding any information that you feel is relevant to the participant’s ability to participate in the internship/training program. Show the physician/practitioner PDFs #11 and #16 with your filled answers.

1 Allergies. Does the participant have any dietary restrictions or known allergies that the program should be aware of? If yes, please provide details (e.g., allergy types, severity, medication, previous history). ☐ Yes ☐ No

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2 Chronic or serious medical condition. Does the participant currently have, is the participant currently receiving treatment for, and/or has the participant been previously treated for any chronic or serious medical condition that the program should be aware of? If yes, please provide details (e.g., diseases/disorders, recommendation for ongoing/emergency treatment, medication). ☐ Yes ☐ No

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3 Disability. Does the participant require accommodations to a disability to enable them to participate in this program? If yes, please provide details. ☐ Yes ☐ No

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www.fusia.net/physicianexam

4 Medical contraindications. To the best of your knowledge, are there medical contraindications and/or other factors which may preclude this participant from interning/receive training in the US and/or present a need for treatment while in the US? If yes, please provide details. ☐ Yes ☐ No

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5 Verdict. Do you consider that the participant is mentally and physically fit to attend an internship/training program in the US? Indicate any additional information (e.g., further evaluation through another mental health/counselling provider is required, weekly/monthly medical check-ups during the program) that would be helpful for the program to be aware regarding the participant’s health condition. ☐ Yes ☐ No

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Body check for (name) (gender) (DOB) Email (email)

Weight _______________ ☐ Lbs ☐ Kg Remarks (if any) __________________________________________________________________

Pulse _______________ bpm Remarks (if any) ___________________________________________________________________________

Blood Pressure _______________ systolic/diastolic Remarks (if any) _____________________________________________________

Physician/practitioner’s signature/stamp

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Signature date: EST ................................... Name of the physician/practitioner

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Contact details

www.fusia.net/physicianexam

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