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Dear parents, here you can find a lot of useful information about raising a bilingual child. We will help and guide you towards the right specialist who will be able to teach your child to speak like a native

parents
 

Medical questionnaire

MEDICAL EXAMINATION

 

Every candidate fills  in the following form on the basis of his previous analyses. Unfortunately, according to the UK law, we cannot request the results from a medical center, because it is confidential. A candidate must  fill  in the following form, and in the case of  if he or she gives wrong information, this person will be exposed to a criminal liability. All of our specialists are ready to pass the tests and examinations that are needed  for living in Russia, UAE , the Ukraine, Switzerland and other countries, according to the country's and employer`s demands.

 

MEDICAL QUESTIONNAIRE

STRICTLY CONFIDENTIAL

 

Surname: Mr./Mrs./Miss/              

All Forenames   __________________________________________

Address________________________________________________

Post Code   _____________________________________________

Age   __________________________________________________

Date of Birth ____________________________________________

Marital Status   __________________________________________

 

State if you have suffered from any of the following:

 

YES/NO

 

YES/NO

Tuberculosis

 

Epilepsy

 

Coughing Blood

 

Sciatica

 

Coughing or hoarseness (for more than 7 days)

 

Genito-Urinary Complaints

 

Pneumonia or Pleurisy

 

Asthma

 

Rheumatic Fever (Rheumatism)

 

Slipped Disc

 

Appendicitis

 

Back Trouble

 

Stomach or Bowel Complaint

 

High or Low Blood Pressure

 

Diabetes

 

Heart condition/Angina

 

Infection of Kidneys

 

Regular Fainting or Migraine

 

 

Have you ever had any specialist or hospital investigation, X-Ray or E.C.G.?   Yes/No  ____________________________

Is any investigation pending?  Yes/No   If Yes please specify________________________________________________

Have you suffered any physical injury? Yes/No If so state when and how ______________________________________

Are you at present on any form of treatment or medical advice? Yes/No If so please specify   _______________________

Have you had any specialist medical advice in the last two years?  Yes/No _____________________________________

Have you lost any work time (over 5 days per time) through illness or injury in the past three years? Yes/No ____________

If so, for what and for how long _______________________________________________________________________

Do you feel in good health generally? Yes/No   __________________________________________________________

How many cigarettes do you smoke per day?  ___________________________________________________________

I hereby confirm that the information given to English Nanny is true and correct. I consent to my personal data  being forwarded to clients. I understand that should it be proved subsequently that I have misrepresented any material fact on this questionnaire I may be summarily dismissed

 

 

 

APPLICANTS SIGNATURE  _______________________  Date ____________

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