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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