3a Health

(e*ifirate

FOROffTCE

AFS ID#

To be completed and signed by the carrdidate's physician- The physician should not be related to the candidate. Eadr
question must be aaswered with a
ineluded or attached ia a separate report for 'YES" resporues to

detailed

guestions *9,11-13. AIS reserves the right to ask for further infornration and deterntine if the candidate meets the pre'
gram medical gualifications. The candidate aad parent/guardian rnrst also siga

ttn

I4r" Muhqmud Nqbil

(Ms.) (Mr) Candidate Name

Adha

(First/Middie/Last)

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w .AprrL tgfr

tvrdmed,r,

Home

Country

Birthdate

xepir.uon t6

vrc Y&9 Fuise 7,'

BloodType o

Hdght

Do you note any abnomalities concerningleighg weight (inctuding substantial loss or gain in &e past six months} blood
pressure, pulse or respiration? [1 Y& Eltrlo [f yes, explain

YES I{O

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V

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IFXNOUUIh

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Titer:-Da!e:-

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Titer:-Date:
tr
Titer:-Date:
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tr
{fyes,morrthlyear.e) Poliorryelitis tr W
f)Hepatitis il,P
g) TubercuJosis n Al
a)

Measles

bi Mumps
c) Rubella
d) ChickenPox

If yes, give detailed infonnation and dates

(r.:se

h)
i)
i)
k)
l)

RheumaticFriver

tr

Cough (persisteng

Headaches(persisterr!recurring)
Sleepwalking "

tr
tr
tr

Enuresis

m) Appendicitis

n)

Parasites(internati

If yes, identify

At IERGIT

I{ yes, identi{y type, any rnedication taken, name dmage & frequenqy:

AsrHmA n

Dl*aErEs

If yes, identify tyge, severity, any medication taken, name, dosage & freguenqp

fl Yes E{Vo

If yes, identify type, severity, any medication taksr, name, dosage & frequmry:

Yes M{.1"

If

a) Abdominal organs, digestive systern il

b) Lungs,respiratorysystem tr
c) Bones, joints, locomotor system
tl
d) Genito-'urinary system
il
If yes, please explain

dvo

[J

No If yes, glve

vg

yes, identify type, severity, an)r medication takerl nane, dosage & frequency:

?E$

(erse

area, severity, any medication taken, narne, dosage & frequency:

Yes E76Io

.scIzuRE fl
D|sONDEN

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n

extra pages if necessary):

4 ACHG [l Yes {*,

[ Yes E6fo

NO

YES

NO

d
V
V
d

Heartblood vessels
Tonsils nose or throat

Blood, endocrine system

Eyes /

extra pages, #necessary )

dates, diagnosirs and outconne for eaeh inciderrt-

diarrhaa.rv@va

visior; ear/haring

NO

ntr

DW
NW

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