medical summry report

[earthborn]

madical formu hakkında bilgisi olan var mı?

[BannedUser]

ne icin drug test mi

genelde isterler fastfood ve lifeguard işlerinde...

[earthborn]

bilmiyorum self gideceğim otelde çalışacağım şirket istedi

[earthborn]

https://mail.google.com/mail/?ui=2&i...f_gxumua0q0&zw
bu belge bilgisi olan yok mu

[captain89]

Belge goruntulenemiyor. Buyuk ihtimal kendi mailinden link verdin.

[earthborn]

Belge goruntulenemiyor. Buyuk ihtimal kendi mailinden link verdin.

evet mail linki vermişim bende kopyaladım
2012 Medical Summary Report
American Work Experience • 335 Greenwich Avenue • Greenwich, CT 06830 • USA
Phone: (+203) 661-9352 • Fax: (+203) 869-6491 • E-mail: info@aweusa.com • American Work Experience (AWE)
INSTRUCTIONS: As a participant on the American Work Experience programme, you
are required to have a physical exam before departing for the U.S. This form must be
completed and signed by a licensed physician. This form does not affect your employer’s
decision to hire you or determine your acceptance onto the AWE programme. However,
falsifying or failing to disclose information about your health may result in immediate
dismissal. If you have any questions or concerns, please contact the AWE office.
Note: Both the applicant and physician must sign this form. Please send
the original form to AWE and keep a copy for your records.
IMPORTANT:
The doctor MUST place his/
her official stamp here.
Alternatively, a signed
business card or official
letterhead must be attached.
Please use the other side of this form if you have any additional comments
AWE # ____ -- _________
Name __________________________ Birthdate ____/____/_______ Age _____ ❏ Female ❏ Male Do you smoke? ❏ Yes ❏ No
Complete home address __________________________________________________ _________________________________________
Home phone _____________________ Work phone __________________________ Fax ______________________________________
Emergency contact name ___________________________________Relationship _____________________________________________
Emergency contact phone ________________ Work phone _______________ Fax ____________________________________________
Alternate emergency contact name ___________________________________ Phone _________________________________________
List any surgery or major illnesses you have had in the last 18 months (include dates): _________________________________________
List any chronic, recurring illnesses or medical conditions: __________________________________________________ ______________
Have you ever been under a professional’s care for emotional or psychological difficulties? ❏ Yes ❏ No If yes, please describe:
__________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ ____________
Do you have any dietary restrictions? ❏ Yes ❏ No If yes, please describe: ______________________________________________
Do you consume alcoholic beverages: ❏ Yes ❏ No If yes, please describe: ______________________________________________
I hereby certify that the above information is true and correct to the best of my knowledge and I authorize the
insurance company or AWE to obtain any information acquired in the course of my examination or treatment.
Applicant’s signature __________________________________________________ __ Date __________________________________
Illness/conditions/allergy history (please give dates when possible):
❏ frequent ear infections ___________ ❏ epilepsy _____________ ❏ asthma _____________ ❏ mononucleosis _________
❏ heart defect/disease _____________ ❏ diabetes _____________ ❏ hay fever ____________ ❏ depression ____________
❏ migraine headaches _____________ ❏ tuberculosis __________ ❏ ivy poisonings ________ ❏ mental illness __________
❏ hypertension ___________________ ❏ measles/German______ ❏ insect stings __________ ❏ anorexia ______________
❏ bleeding/clotting disorder _________ ❏ chicken pox __________ ❏ penicillin _____________ ❏ bulimia________________
❏ other_____________________________________________ ___ ❏ other drugs______________________________________
Immunization history (please provide dates):
DPT series (Diphtheria, Pertussis, Tetanus) __________ Polio ________________ Typhoid ________________________
MMR (Mumps, Measles, Rubella) __________________ Smallpox ____________ Tetanus Booster__________________
Hemophilus Influenza B (HIB) _____________________ Hepatitis B ___________ Tuberculin test ___________________
❏ Pos. ❏ Neg.
Recommendations: This participant will be working in the United States for up to four months. All positions involve long hours and
are very demanding. Is there any information the employer needs to know regarding the applicant’s mental or physical condition?
__________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ ____________
Any treatment to be continued while in the U.S.? __________________________________________________ ______________________
Any medications to be administered while in the U.S.? (indicate dosages) __________________________________________________ __
Additional comments __________________________________________________ ____________________________________________
Physician’s name __________________________________ Address ________________________________________________
Phone _______________________ Fax _________________________ Email address _________________________________________
Signature __________________________________________________ _______________Date __________________________________
I. TO BE COMPLETED BY THE PARTICIPANT:
II. TO BE COMPLETED BY THE PHYSICIAN
American Work Experience • 335 Greenwich Avenue • Greenwich, CT 06830 • USA
Phone: (+203) 661-9352 • Fax: (+203) 869-6491 • E-mail: info@aweusa.com • American Work Experience (AWE)
2012 Medical Summary Report
Medical Summary Report
Please use this side for additional comments you wish to make, or to provide more details.
"AWE.., going further to bring people together!"