DELEGATION TEXCOCO MEDICAL SERVICES AREA

R.F.C. CRM 670210 9K6

Medical Certificate N° 94008

NOMBRE: _________________________________________________________ SEX: M F AGE:________________

Paternal Last Name Maternal Last Name First Name (S) (years)
DOMICILIO: __________________________________________________________________________________________________
Street No. Ext. No. Int. Col/Locality Municipality CP
DATE OF BIRTH: ________ / ____________ / _________ GROUP/RH:__________________________________
Day Month Year
ELIGIBLE AT: IMSS______ ISSSTE ________ ISSEMYM______ OTHER ___________ NONE____________________
(IF UNDER 18 YEARS OF AGE, PLEASE PROVIDE NAME OF PARENT OR GUARDIAN)
NAME: ________________________________________________________ RELATIONSHIP: ______________________________
Paternal Surname Maternal Surname First Name (S)
VITAL SIGNS: FC________ FR__________ T/A_____________ WEIGHT _________ SIZE ________________________

EXANTHEMATOUS DISEASES: YES___________ NO _________ INFECTIOUS DISEASES: YES________ NO _________________

MEASLES ______ RUBELLA______ VARICELLA______ HEPATITIS________ SCARLET FEVER_______OTHER______________________

SURGERIES: YES _______ NO

______________________________________________________________________________________

____________________________________________________________________________________________________________

ALLERGIES: YES________
NO______________________________________________________________________________________

TRANSFERS: YES_____ NO___________________________________________________________________________________

CURRENT DISEASES OF IMPORTANCE: ______________________________________________________________________

____________________________________________________________________________________________________________

MEDICACIÓN ACTUAL: _________________________________________________________________________________________

6. IN YOUR OPINION, THE APPLICANT'S MENTAL HEALTH CONDITIONS ARE:

EXCELLENT ( ) GOOD ( ) FAIR ( ) FAIR ( ) BAD ( ) POOR ( )

ESPECIFIQUE:_________________________________________________________________________________________________

7. INTERPRETATIVE RESULTS OF LABORATORY AND/OR LABORATORY TESTS: ______________________________________

____________________________________________________________________________________________________________
THE UNDERSIGNED C: _________________________________________________ PHYSICIAN SURGEON, LEGALLY
AUTHORIZED TO PRACTICE THE PROFESSION AFTER HAVING PERFORMED A THOROUGH MEDICAL EXAMINATION,
CERTIFIES THAT THE PATIENT IS:
APT_______ NOT APT _______ FOR ______________________________________________________________

OBSERVATIONS: DESCRIBE ANY ABNORMALITIES OBSERVED IN THE PATIENT AND THE RESULTS OF YOUR MEDICAL EXAMINATIONS.
PLEASE PROVIDE ANY COMMENTS YOU MAY HAVE.

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________
DIAGNÓSTICO CLÍNICO: _____________________________________________________________________________________
THE PRESENT DOCUMENT IS ISSUED FOR THE USES AND LEGAL PURPOSES THAT MAY BE CONVENIENT FOR THE
INTERESTED PARTY.
AV HIDALGO S/N COL. LA CONCHITA C.P. 56170 TEXCOCO EDO. DE MEX TELS.01(595)9540328 *9554332
 DELEGATION TEXCOCO MEDICAL SERVICES AREA
R.F.C. CRM 670210 9K6
Medical Certificate

AV HIDALGO S/N COL. LA CONCHITA C.P. 56170 TEXCOCO EDO. DE MEX TELS.01(595)9540328 *9554332