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British Medical Examination Registration Form

Medical history

  • 1. Has the applicant (or their child) had any of the following symptoms in the last three months: Cough, Fever,Haemoptysis,Night sweats,Weight loss

    • 2. Is there any history of previous TB?

    • Has anyone in the household been diagnosed with TB in the last 2 years?

    • Is there any history of recent contact with a case of active pulmonary TB (shared the same enclosed air space or household or other enclosed environment for a prolonged period for days or weeks)?

  • 3. Have you ever had thoracic surgery, including heart, lungs, breasts, spine and chest wall, neck or upper belly surgery?

  • 4. For women only: Are you pregnant?

  • 5. For children only:
    Is there any history of the following; any chronic respiratory disease, such as cystic fibrosis, previously thoracic surgery ,cyanosis, respiratory insufficiency that limits activity.

Please sign to confirm the medical history(The signature of the applicant under the age of 16 or the incapacitated person shall be signed by the guardian.)
After you submitted the form, the part below the line needs to be printed and handwritten.
  • Signature:

  • Date:

(Note: Please fill out the form and print it in advance. The form must be signed at the clinic.)

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