Free Medical Report for Visa Template
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
