Medical Report for Visa

Medical Report for Visa

[Date]

I. Patient Information

Name: [Patient's Name]

DOB: [Patient's Date of Birth]

Nationality: American

II. Medical History

A. Previous Medical Conditions

[Patient's Name] has a history of asthma and seasonal allergies but has experienced minimal symptoms over the past five years. There are no records of any chronic illnesses or significant surgeries.

B. Current Medications

Medication

Dosage

Frequency

Albuterol

90 mcg

As needed

Loratadine

10 mg

Once daily

C. Immunization History

[Patient's Name] is up-to-date with routine vaccinations, including tetanus and influenza vaccines.

III. Physical Examination

Measurement

Result

Normal Range

Blood Pressure

120/80 mmHg

90/60 - 120/80 mmHg

Heart Rate

72 bpm

60-100 bpm

Temperature

98.6°F

97.8°F - 99.1°F

Respiratory Rate

16 breaths per minute

12-20 breaths per minute

IV. Laboratory Results

Test

Result

Normal Range

Hemoglobin

14.0 g/dL

13.8-17.2 g/dL

White Blood Cell Count

5,500/mm3

4,000-11,000/mm3

Platelet Count

250,000/mm3

150,000-450,000/mm3

Cholesterol

180 mg/dL

< 200 mg/dL

V. Assessment

Based on clinical evaluation and laboratory findings, [Patient's Name] is in good health and meets the health requirements for the work visa application to [Destination Country]. Overall health is good and he is fit to travel. There are no evident medical conditions that would restrict or complicate his ability to live or work abroad.

VI. Recommendations

[Patient's Name] is recommended for approval of his visa application pending submission of this medical report and supporting documentation.

VII. Doctor's Information

Physician: [Your Name]

License Number: 123456

Contact Number: [Your Phone Number]

Email: [Your Email]

Prepared by:

[Your Name]
Physician

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