USA MEDICAL QUESTIONNAIRE

(MUST be completed and signed by applicant prior to medical appointment)
CASE NUMBER:	                                       VISA APPOINTMENT DATE:	
NAME: (Last)	                                                   (First)	                        Middle)	
DATE OF BIRTH:	                                       AGE:    GENDER:           male                    female 	
BIRTHPLACE:	(City/Country)	
PRESENT COUNTRY OF RESIDENCE:	
PRIOR COUNTRY:	
NATIONALITY:	                                         OCCUPATION:	
CURRENT ADDRESS:

TEL:	
HEIGHT (in centimetres):	WEIGHT (in kilos):	
		YES	NO	
1	Have you ever been hospitalized (including psychiatric admission)?			
2	Have you ever had a disease of your heart or circulation?			
3	Have you ever had a disease of your lungs?			
4	Have you ever used tobacco?			
5	Have you ever had tuberculosis?			
6	Have you ever had a stroke, seizures or other neurological disorder?			
7	Do you have a major impairment in learning, intelligence, selfcare, memory or communication?			
8	Have you ever had any mental disorder or depression?			
9	Have you ever misused or abused drugs?			
10	Have you ever had an addiction to or abused alcohol?			
11	Have you ever caused deliberate injury to yourself or others?			
12	Have you ever caused deliberate damage to property or had trouble with the law because of a mental condition, mental disorder or while under the influence of alcohol or drugs?			
13	Have you ever had any sexually transmitted disease?			
14	Have you ever had yaws, leprosy or malaria?			
15	Have you ever had diabetes mellitus or other endocrine disorder?			
16	Have you ever had a malignancy (cancer)?			
17	Have you ever had any kidney or liver disease?			
18	Do you have any visible disability (including loss of arms, legs or eyes)?			
19	Is any medical treatment (including surgery) pending or anticipated?			
20	Do you take any medication? (Please list of medications on reverse)			
21	Are you pregnant?			
	If the answer is yes, please provide evidence of pregnancy/copy of pregnancy test result.
Date of last period:	Expected delivery date:	

DATE:             	SIGNATURE:	

If you have answered YES to any of the above, please use a separate sheet to give further details.

IV	18a (IV medical) — 12/05
Knightsbridge
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