Page 25 - DIDC SOPS and Guidelinesv as of April 2019

Basic Medical Examination Form PMO-6018-01-d

Contingency Released Date
Operations 04/11/18 Page 1 of 4

I CERTIFY THAT THE STATEMENTS MADE BY ME BELOW ARE TO THE BEST OF MY KNOWLEDGE TRUE, COMPLETE AND CORRECT

Date Signature of candidate

PAGES 1 AND 2 ARE TO BE COMPLETED BY THE CANDIDATE

FAMILY NAME (IN BLOCK CAPITALS) GIVEN NAMES MAIDEN NAME SEX

ADDRESS (STREET, TOWN, DISTRICT, OR PROVINCE COUNTRY) DATE OF BIRTH RACE

SSN # TELEPHONE

Each question requires a specific answer (yes, no, date, etc.); to leave a blank or draw a line is not sufficient. If the
questionnaire is not fully completed and inquiries are therefore needed, time may be lost.

1. Have you suffered from any of the following diseases or disorders? (Yes or No) If Yes, state the year.
10. Heart and
1. Frequent sore blood vessel 19. Urinary 28. Fainting spells
throats disorder
disease

11. Pains in the
2. Hay fever 20. Kidney trouble 29. Epilepsy
heart region
3. Asthma 12. Varicose veins 21. Kidney stones 30. Diabetes
13. Frequent 31. Any sexually
4. Tuberculosis 22. Back pain
indigestion transmitted disease
14. Elevated
5. Pneumonia 23. Joint problems 32. Topical disease
Cholesterol
33. Amoebic
6. Pleurisy 15. Jaundice 24. Skin disease
dysentery
7. Repeated 16. Gall stones 25. Sleeplessness 34. Malaria
bronchitis
26. Any nervous or 35. Sleep
8. Rheumatic fever 17. Hernia
mental disorder Disorders
36. Ulcer of
9. High blood 27. Frequent
pressure 18. Hemorrhoids headache stomach or
duodenum

Please explain any “Yes” responses from 1 - 36 noted above:

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