Nationwide Health Systems CHILD / PWD / SENIOR : _____________

BAGUIO, Inc DATE:___________________ NON-EDE/ XSD / EDE / APPT ______

Referred by: IME/ UMI
a. Self (family/friend/internet) c. Immigration consultant HAP/ NZER: ________________________________
b. Embassy information d. Company / Recruiter / Agency
PLEASE FILL UP DOTTED BOXED AREA ONLY NEW MED / REMEDICAL: ________________
INTENDED LENGTH O
PREFERRED PHILIPPINE CONTACT NUMBERS AND ADDRESS: CLIENT INFORMATION:

Cellphone: ____________________________/_____________________________ Last Name: _______________________________________

Email Address: ______________________________________________________ First Name:_______________________________________
Address: ____________________________________________________________ Middle Name: ____________________________________
__________________________________________________________ Age: __________ Gender: _________ Civil Status: ______________
expire in 6 months?
Passport Number: ________________________________ (YES/NO) Date of Birth: Day / Month / Year
If applicable
Other ID: _____________________________________________ Last Menstrual Period: Date Started / Date Ended

Intended Occupation / Activity / Study (Course): ______________________________________________________________________________________

a. Is this your or your family's first visa related medical examination? Please encircle YES NO
b. Has your or your family's application for a visa ever rejected before? Please encircle YES NO
c. NEW ZEALAND APPLICANTS INTENDED LENGTH OF STAY? Please encircle Less than 6 mos / 6 - 12 mos / 12 - 24 mos / more than 24 mos
I. RESIDENCE ( Skilled - Business / Pacific Categories / Family / Humanitarian UNHCR / Humanitarian - other)
VISA CATEGORY
II. TEMPORARY ( Visitor / Student / Work with job offer / Work without job offer)
Please encircle
III. WORK TO RESIDENCE ( Worker / Family Worker )
d. CANADA APPLICANTS Did you receive a letter that your application is under review based on the new public
policy effective 1 June 2018? Please encircle
YES NO
if UPFRONT MEDICAL, what is your VISA CATEGORY? Please encircle VISITOR STUDENT WORKER (Express Entry) Attach
recent
e. AUSTRALIA APPLICANTS If you are applying for a Temporary visa, do you intend to apply for a permanent stay
in Australia with in the next 6 -12 months? Please encircle YES NO Photo
Would you like your health to be assessed “upfront” for a permanent stay in Australia? Please encircle YES NO
Do you intend to work or study to be a Nurse / Physician / Dentist / Paramedics? Please encircle YES NO
DECLARATION BY EXAMINEE (OR PARENT GUARDIAN IF UNDER 16 YRS OF AGE)

I declare that the information given above are TRUE and CORRECT. ________________________________________________________
Print Name and Sign (Examinee or Accompanying Parent/Guardian if 16 yrs old and below)
Father / Mother / Grandmother / Grandfather / Uncle / Aunt / Guardian / Brother / Sister
FOR NHSBI STAFF ONLY
TIME IN TIME OUT INITIAL
CPE, Urinalysis, RPR, HIV, Hbsag, Anti-Hcv, FCBC, HBA1C, eGFR, CXR
INITIAL INTERVIEW:
CPE, Urinalysis, RPR, HIV, Hbsag, full CBC, Crea, LFT, CXR
CONSENT:
CPE, Urinalysis, HIV, Hbsag, Anti-HCV, CXR
SCAN/PICTURE:
CPE, Urinalysis, RPR, HIV, CREA, CXR
PRE-EXAM:
CPE, Urinalysis, HIV, CXR OTHER TESTS
CPE, Urinalysis, CXR UA-Dips tick IGRA
CASHIER: CASH/ADV DEPOSIT
CPE, Urinalysis UA-Micros copy CALCIUM RECEIPT/LOGBOOK
PREG TEST HBeAG
CPE Only HIV HBV - DNA
LABORATORY: URINALYSIS
HBSAG Liver Fibro Scan BLOOD TEST
NHSBI METRO ANTI-HCV ECG DOH
FBS CHEST UTZ
ADD'L TEST
LIPID PROFILE LGBP UTZ
S. CREA CXR - PA
To tal M edical
To tal Cash P aid
BUA CXR - APL CHEST X-RAY: PA VIEW
Fee AFP CXR - APICO
LFT CXR - R LAT
ADD'L VIEW
Signature Change
SGPT CXR - L LAT
A dd'l Fee A dd'l Fee
FCBC CXR - LOR HEIGHT AND WEIGHT:
EGFR CXR - R OBL
A dd'l Fee A dd'l Fee TPPA CXR - L OBL PHYSICAL EXAM:
UPC CXR - SPOT REFERRAL:
To tal A dd'l Fee To tal Cash P aid FERRITIN
Signature Change

TOTAL MEDICAL FEE PAID FINAL INTERVIEW: WAITING AREA

(2ND FLOOR EXTENSION AREA)

Pertinent Laboratory Findings: circle/highlight/add required tests (MARK "N" for NORMAL RESULTS)
_UA_ RPR _HIV HBSAG ANTI-HCV _CXR_ EGFR FCBC HAIC RPT UA CREA _ECG_ LFT_ LGBP FBS_ FLIPID _____ ______ __ ___ ______

Blood Pressure Body Temp: __________ Uncorrected / Corrected

PH
Initial: _____/_______ BMI: ________________ Height in cm: __________ OS/L _________/__________ GLASSES
CONTACT LENS
Repeat: _____/_______ Head Cir: _____________ Weight in kg:__________ OD/R_________/__________
PERTINENT HISTORY OR PHYSICAL EXAMINATION: Recommendations/Comments/Notes
GRADING J
A
N
A B
2
SUBMITTED BY: 0
2
_________ 0

__________________
BARCODE