‫ﻧﻤﻮذج ﻃﻠــﺐ اﻟﻔﺤـــﺺ اﻟﻄــــﺒﻲ‬

‫ﺻــــﻮرة‬

Medical Examination Application Form

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Personal Details ‫اﻟﺒﻴﺎﻧﺎت اﻟﺸﺨﺼﻴﺔ‬

Age: :‫اﻟﺴـــﻦ‬ Name: :‫اﻻﺳﻢ‬

No. Facility: :‫رﻗﻢ اﻟﻤﻨﺸﺎة‬ Facility Name: :‫اﺳﻢ اﻟﻤﻨﺸﺄة‬

Candidate's Job: :‫اﻟﻮﻇﻴﻔﺔ اﻟﻤﺮﺷﺢ ﻟﻬﺎ‬ Gender: :‫اﻟﺠﻨﺲ‬

Employer’s Details ‫ﺑﻴﺎﻧﺎت ﺟﻬﺔ اﻟﻌﻤﻞ‬

Establishment or Responsible Manager Name: :‫اﺳــــﻢ ﺻﺎﺣﺐ اﻟﻤﻨﺸﺄة أو اﻟﻤﺪﻳﺮ اﻟﻤﺴﺆول‬

Signture: :‫اﻟﺘﻮﻗﻴﻊ‬

Stamp ‫اﻟﺨﺘﻢ‬

Medical Information ‫اﻟﻤﻌﻠﻮﻣﺎت اﻟﺼﺤﻴﺔ‬

Left Eye: :‫اﻟﻌﻴﻦ اﻟﻴـﻤﻨـﻰ‬

Right Eye: :‫اﻟﻌﻴـــﻦ اﻟﻴـﺴﺮى‬

Power of Sight ‫ﻗـﻮة اﻹﺑﺼﺎر‬
Highlight Colors: :‫ﺗﻤﻴـﻴﺰ اﻷﻟﻮان‬

Notes: :‫اﻟﻤــﻼﺣـﻈـﺎت‬

Clenic Examination: :‫اﻟﻔﺤﺺ اﻟﻜﻠﻴﻨﻜﻲ‬

Chest: ‫اﻟﺼـــﺪر‬
Radiography: :‫اﻟﻔﺤـﺺ ﺑﺎﻷﺷﻌـﺔ‬

Heart: :‫اﻟﻘﻠﺐ‬

Blood Blood Pressure: :‫ﺿﻐﻂ اﻟﺪم‬

Circulation
‫اﻟـﺪورة اﻟـﺪﻣﻮﻳـﺔ‬
Arteries :‫اﻟﺸﺮاﻳﻴﻦ‬

Veins status: :‫ﺣﺎﻟﺔ اﻷوردة‬

Nervous System ‫اﻟﺠﻬﺎز اﻟﻌـﺼـﺒﻲ‬

Hernia ‫اﻟـﻔـﺘـﻖ‬

Disabilities ‫اﻟـﻌـﺎﻫـﺎت‬

Urine Diabetes: :‫اﻟﺴـﻜﺮ‬

Examination ‫ﻓﺤـﺺ اﻟـــﺒﻮل‬
Albumin: :‫اﻟﺰﻻل‬

Stool
Examination If necessary ‫إذا ﻟﺰم اﻷﻣﺮ‬ ‫ﻓـﺤـﺺ اﻟــﺒـﺮاز‬
Bright blood
Examination If necessary ‫إذا ﻟﺰم اﻷﻣﺮ‬ ‫ﻓﺤﺺ اﻟﺪم اﻟﺰاﻫﻲ‬
Venereal
‫اﻷﻣﺮاض اﻟﺘﻨﺎﺳﻠﻴﺔ‬
Diseases

Final Result ‫اﻟـﻨﺘﻴﺠﺔ اﻟـﻨﻬﺎﺋﻴﺔ‬

* This form is considered void in case of any scratch or change after printing. ً
.‫ﻻﻏﻴﺎ ﻓﻲ ﺣﺎل أي ﺷﻄﺐ أو ﺗﻐﻴﻴﺮ ﺑﻌﺪ اﻟﻄﺒﺎﻋﺔ‬ ‫* ﻳﻌﺘﺒﺮ ﻫﺬا اﻟﻨﻤﻮذج‬
 Signatures
Approvals ‫اﻟﺘﻮﻗﻴﻌﺎت‬
‫اﻻﻋﺘﻤﺎدات‬
Committee Chairman ‫رﺋﻴﺲ اﻟﻠﺠﻨﺔ‬ Doctor 2 2 ‫ﻃﺒﻴﺐ‬ Doctor 1 1 ‫ﻃﺒﻴﺐ‬

Date: :‫اﻟﺘﺎرﻳﺦ‬ Date: :‫اﻟﺘﺎرﻳﺦ‬ Date: :‫اﻟﺘﺎرﻳﺦ‬

Stamp ‫اﻟﺨﺘﻢ‬

* This form is considered void in case of any scratch or change after printing. ً
.‫ﻻﻏﻴﺎ ﻓﻲ ﺣﺎل أي ﺷﻄﺐ أو ﺗﻐﻴﻴﺮ ﺑﻌﺪ اﻟﻄﺒﺎﻋﺔ‬ ‫* ﻳﻌﺘﺒﺮ ﻫﺬا اﻟﻨﻤﻮذج‬