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The $ev_name facilitates the conduction of an examination as per the program’s needs and allows the documentation of crucial health information, along with providing relevant advice of the participant. Please download the form from the respective panel, have it completed and signed by a licensed physician/medical practitioner, and upload it at least 72 hours before departure to the US. OEP students may submit their school’s physical exam form in place of this form.

Return www.fusia.net/physicianexam

Dear Physician/Practitioner,

$user_pname_ek (name) $user_sex_ek (gender) $user_dobek (DOB) Email $user_email1_ek (email) will be undertaking an internship/training program in the US from $user_ds_d1ek (start date) to $user_ds_d2ek (end date) for $user_ds_f_w (#) of weeks. We kindly request your assistance in performing a concise examination, responding to the listed questions concerning the participant’s medical history, and providing any additional information that may be pertinent to their involvement in the program. Please ensure that all the above fields are filled out by pen or typing.

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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6 Body check for $user_pname (name) $user_sex_ek (gender) $user_dob (DOB) Email $user_email1 (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 $date_sign EST .......................................... Full name and details of the physician/practitioner

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Contact details

☐ Self-endorsement (prior approval from FUSIA is required). Participants who have obtained prior approval from FUSIA are allowed to endorse their health form themselves. In the event that the participant completes this form without the endorsement of a physician, we kindly request you to affix your signature below. By doing so, you are validating the accuracy of the information provided and confirming that the participant does not have any health issues, whether hidden or explicitly mental or physical, that may jeopardize their participation in the program. Additionally, please ensure that all the above fields are filled out by pen or typing.

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Signed by $user_pname on $date_sign EST ......................... Signed by $user_fn2’s $user_y405a_ek $user_y405b $user_y405c