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12 of 12F-Declaration-to be completed by Medical Practitioner carrying out the examination Please ensure all sections of the form have been completed. Failure to do so will result in the form being invalid. At the time of the physical examination and completion of this medical form, I had possession of the individual's... |
2 of 12A-Personal Details B-Registered NHS GP Details A1 Surname A2 Forename(s) A3 Date of Birth DD M MYYYY A4 Current Address Postcode Rest of address B1 Name of Registered NHS GP B2 Address Postcode Premises number Rest of address TM004291 TPH/204 Medical Declaration Form Part 1 June 18This page is to be f ully compl... |
10 of 128 Psychiatric Does the applicant have a history of: Yes No (a) Psychiatric Disorder (b) Psychotic Illness (c) Dementia/Cognitive Impairment (d) Alcohol Misuse (e) Alcohol Dependency (f) Drug or Substance Misuse (g) Drug or Substance Dependency 9Any other conditions Yes No (a) Does the applicant named in section... |
4 of 12Tf L recommends that all individuals take a photocopy of this form once it is completed for their own record before submitting the original. D-Medical Conditions-to be completed by Medical Practitioner Sections D-F must be completed by a Medical Practitioner who should:-Have access to the individual's full medic... |
8 of 126Neurological Does the applicant have a history of: Yes No (a) Seizure/Epileptic attack and/or having taken anti-convulsant/epileptic medication in the last 10 years (b) A first unprovoked epileptic seizure/solitary fit within the last 5 years (c) Blackout/Impairment of Consciousness (d) Stroke/TIA If 'Yes', pleas... |
6 of 123 Other Cardiovascular disease/procedure Does the applicant have a history of: Yes No (a) Aortic aneurysm If 'Yes'. please provide the following: (i) Site of aneurysm Thoracic Abdominal (ii) Has it been successfully repaired? (iii) Please provide size of aortic diameter.............................................. |
6 of 123Other Cardiovascular disease/procedure Does the applicant have a history of: Yes No (a) Aortic aneurysm If 'Yes'. please provide the following: (i) Site of aneurysm Thoracic Abdominal (ii) Has it been successfully repaired? (iii) Please provide size of aortic diameter............................................... |
8 of 126 Neurological Does the applicant have a history of: Yes No (a) Seizure/Epileptic attack and/or having taken anti-convulsant/epileptic medication in the last 10 years (b) A first unprovoked epileptic seizure/solitary fit within the last 5 years (c) Blackout/Impairment of Consciousness (d) Stroke/TIA If 'Yes', plea... |
4 of 12Tf L recommends that all individuals take a photocopy of this form once it is completed for their own record before submitting the original. D-Medical Conditions-to be completed by Medical Practitioner Sections D-F must be completed by a Medical Practitioner who should:-Have access to the individual's full medic... |
10 of 128 Psychiatric Does the applicant have a history of: Yes No (a) Psychiatric Disorder (b) Psychotic Illness (c) Dementia/Cognitive Impairment (d) Alcohol Misuse (e) Alcohol Dependency (f) Drug or Substance Misuse (g) Drug or Substance Dependency 9 Any other conditions Yes No (a) Does the applicant named in sectio... |
2 of 12A-Personal Details B-Registered NHS GP Details A1 Surname A2 Forename(s) A3 Date of Birth DD M MYYYY A4 Current Address Postcode Rest of address B1 Name of Registered NHS GP B2 Address Postcode Premises number Rest of address TM004291 TPH/204 Medical Declaration Form Part 1 June 18This page is to be fully comple... |
12 of 12F-Declaration-to be completed by Medical Practitioner carrying out the examination Please ensure all sections of the form have been completed. Failure to do so will result in the form being invalid. At the time of the physical examination and completion of this medical form, I had possession of the individual's... |
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