| 1. What medical problems do you have at present? Describe in detail. |
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| 2. Our method requires a lot of standing, do you think you will have
a problem with this? |
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YES
NO |
| 3. Smog is sometimes a problem in Santiago, do you think you will have
a problem with this? |
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YES
NO |
4. HAVE YOU EVER HAD OR HAVE YOU NOW: (Please check to the left of each
item)
For each question marked "YES" explain fully on the reverse
of this page including DATES. Number each explanation. Use additional
sheets if required. |
| YES/NO < CHECK EACH ITEM |
Sinusitis
Fequent or severe headaches
Migraine
Bronchitis
Tuberculosis
Shortness of breath
Pain in the chest
Heart disease
Low or high blood pressure
Dizziness or fainting spells
Stomach/Gastrointestinal trouble
Allergies
Varicose veins
Arthritis or Rheumatism
Paralysis (incl. polio)
Joint or spine disorder
Recurrent back pain
Epilepsy or fits
Depression or excess worry
Nervous trouble of any sort
Mental or emotional illness
Physical disability
Asthma
Throat disorders |
| Please answer YES or NO to the following questions |
| 5. Have you ever experienced difficulty in your work because of inability
to perform certain motions or assume bodily positions? ( If yes, explain) |
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6. Have you ever been refused employment or had your employment terminated
because of your health?
(If yes, state reason and give details) |
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7. Have you ever had a major operation?
(If yes, describe and give date, surgeon and hospital) |
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8. Have you ever been a patient (committed or voluntary) in a mental
hospital?
(If yes specify when, where, why, and name of doctor and complete address
of hospital or clinic) |
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9. Have you ever had any illness or injury other than those already
noted?
(If yes, specify when , where and give details) |
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10. Are you having, or have you had a drug, narcotic, or drinking problem?
(If treatment was required, give name of doctor, date, agency and treatment) |
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11. Are you taking medication on a regular basis?
(Most medication is available in Santiago) |
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| Name of Medication TAKEN FOR DOSAGE HOW OFTEN & HOW LONG |
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| 12. IMMUNIZATIONS |
Immunizations recommended are Immune Globulin (IG) and Typhoid
I hereby certify that the statements made by me in this application are
true, complete and correct to the best of my knowledge and belief. I understand
that a false statement, misrepresentation or omission made on the medical
form, application or other documents requested by The Sam Marsalli English
Language Institute, may disqualify me from acceptance and any subsequent
contract or may cause my dismissal . |
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The answers to the above questions will be treated with
strict confidence.
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