Membership no:

Medical Form
PART A To be completed by the Applicant and reviewed by the Doctor
INSTRUCTIONS
PART B To be completed by the Doctor

1 Please complete this form as soon as possible 3 Upload Part A and Part B to the Participant site
2 Take Part A and Part B to your Doctor for review and 4 Please note that the doctor completing this form cannot be a
completion family member

PART A – To be completed by the Applicant and reviewed by the Doctor

Please note that withholding or falsifying any information may result in the applicant being withdrawn from the program

Full Name:

Address:  Female  Male

Date of Birth: _ _ / _ _ / _ _ _ _ Age:

Height:

Weight:

Next of kin – please provide details of the relative or person we can contact in case of emergency when you are in the US

Full Name: Address:

Relationship to you:

Telephone no:

Best time to call:

Tick the appropriate box if you presently suffer from or have ever had/experienced:
 Acne / Skin problems  Eating disorder  Hernia  Rheumatic fever
 Anemia  Emotional abuse  High / Low Blood pressure  Rubella (German measles)
 Anxiety/Nervous condition  Epilepsy/Convulsions  HIV  Scarlet fever
 Arthritis  Eye problems  Kidney disease  Self harming
 Asthma  Gall bladder problems  Learning disabilities  Sexual abuse
 Blood disorders  Gastritis  Malaria  Sleep walking
 Cancer  Genital Herpes  Measles  Suicide attempt
 Chicken pox  Genitourinary problems  Menstrual problems  Thyroid condition
 Cold sores (Herpes 1)  Glandular fever  Migraines/Headaches  Tonsillitis
 Counselling/Psychotherapy  Hearing problems  Mumps  Tuberculosis
 Depression  Heart disease  Orthopaedic problems  Ulcers
 Diabetes  Hepatitis A  Physical abuse  Varicose veins
 Dizziness/Fainting  Hepatitis B  Polio  Other (please specify)
 Ear infection  Hepatitis C
 

If you have ticked any of the above, please provide details including dates and treatments required:

37 Queen’s Gate London SW7 5HR UK Tel: +44 (0)20 7581 7322 V1/2016
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 Membership no:

Medical Form
Have you ever received counselling or sought advice from a psychologist, psychiatrist, counsellor and/or doctor?  Yes  No

Is your physical ability restricted in any way?  Yes  No

Do you take any medications or prescription drugs? If yes, state how often and for which condition below?  Yes  No

Have you ever been treated for alcoholism/drug dependency?  Yes  No

Are you currently taking any medication (including contraceptive pill)?  Yes  No

Is there any history of nervous or emotional problems, depression or abuse (sexual, emotional or physical) in
your family background?  Yes  No

Are you on any medical treatment that will require medical attention during your time as an au pair?  Yes  No

Do you wear braces?  Yes  No

Do you have any limitations that restricts you from lifting a child (i.e. recent surgery/back problems etc)?  Yes  No

If you have answered ‘yes’ to any of the above, please provide details including dates, treatments and medication required:

Do you smoke?  Yes No

If yes, how many cigarettes do you smoke a day? ________________________________

Tick the appropriate box if you suffer from any allergies:

 Insect stings  Hay fever Animals  Food  Smoke  Penicillin  Other drugs  Other
If you have ticked any of the above, please provide details including dates, treatments and medication required:

Other than to have your Medical Form completed by your doctor, when was the last time you visited the doctor and why, including
dates, treatments and medication required:

37 Queen’s Gate London SW7 5HR UK Tel: +44 (0)20 7581 7322 V1/2016
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 Membership no:

Medical Form
** Please note the following questions and answers will not be shared with host families **

Were you ever or have you had a Pregnancy/Miscarriage/Termination?  Yes  No

If you have answered ‘yes’ please provide details including dates, treatments and medication required:

Have you ever suffered from a venereal disease/STI?  Yes  No

If you have answered ‘yes’ please provide details including dates, treatments and medication required:

**************************************************************************************************
I understand and agree that American host families may have access to this Medical Form and I give permission to the Doctor
completing Part B to review all my responses in Part A of this form and to provide or discuss additional medical information, if
requested to do so by Au Pair in America.
Should an emergency situation arise, I authorize any medical provider to release information regarding my condition to Au Pair in
America or their insurance provider/emergency assistance services and understand that they can contact my next of kin without my
prior consent.
The above information is correct to the best of my knowledge and I hereby give permission for emergency medical care to take
place should it be necessary. I also understand that withholding or falsifying any information may result in me being withdrawn from
the program.
I understand that insurance provided through Au Pair in America, including any upgrades, is not designed to cover any pre-existing
or congenital conditions. A pre-existing condition is an illness or injury that I show symptoms of or received treatment for within 1
year before my departure to the United States (the condition does not need to be officially diagnosed to be considered pre-
existing). A congenital condition is an illness that I was born with. Should I participate in the Au Pair in America program and need
medical care for a pre-existing or congenital condition or an event arising from a pre-existing or congenital condition. I understand
that all medical expenses will be my responsibility to pay and as such will arrange any necessary insurance where required. If
required I will upload a copy of my insurance documents to my Participant site upon placement. I understand that dental treatment
is not covered by the Au Pair in America insurance policy and I will see a dentist before I leave for the US.

Signature: _________________________________________________________________ Date: _ _ /_ _ /_ _ _ _

Note: This form must be completed and signed by the applicant. Remember to keep a copy of your fully completed Medical Form and take it with you to the US.

37 Queen’s Gate London SW7 5HR UK Tel: +44 (0)20 7581 7322 V1/2016
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 Membership no:

Medical Form
PART B – To be completed by the Doctor

As an Au Pair in America, the applicant will be living for an extended period of time in the home of a family with young children. Is it
therefore important that we are advised of any physical, mental or emotional health problems or family history issues which may
have a bearing on the applicant’s ability to carry out their duties appropriately. Please note that withholding or falsifying any
information may result in the applicant being withdrawn from the program.

Applicant’s Full Name:

Are you related to the applicant?  Yes  No Please note relatives may not complete this form.

Have you reviewed the 3 pages of information in Part A of this Medical Form that was completed by the applicant?  Yes  No

Do you have access to the patient’s full medical history?  Yes  No

How long have you known the applicant? _________________________________________________________________________

It is a program requirement for the applicant to be immunized against the following:

Tetanus  Yes Date_____________

Measles  Yes Date_____________
Mumps  Yes Date_____________
Rubella (German Measles)  Yes Date_____________

Tuberculosis immunization OR  Yes Date_____________  No

Tuberculosis test OR  Yes Date_____________  No Result:  Positive  Negative
Chest X Ray  Yes Date_____________  No Result:  Clear  Non-clear

Please note: positive test results (unless applicant was immunized against TB) will require a copy of a recent chest x-ray

The following immunizations are highly recommended but not required:

Flu Vaccine  Yes Date_____________  No

Small Pox  Yes Date_____________  No
Typhoid  Yes Date_____________  No
Hepatitis B  Yes Date_____________  No
Diphtheria  Yes Date_____________  No
Polio  Yes Date_____________  No
Whooping Cough  Yes Date_____________  No
Meningitis  Yes Date_____________  No
Chicken Pox – if not previously suffered from  Yes Date_____________  No

Tick the appropriate box if there are any abnormalities to the following system:

Ears, nose and throat Eyes Neuropsychiatric Respiratory system/lungs

Genitourinary Skin Cardiovascular Musculoskeletal
Brain, nervous system Gastrointestinal Metabolic Other ________________

If you ticked any of the above, please provide details including dates, treatment and medication required:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

37 Queen’s Gate London SW7 5HR UK Tel: +44 (0)20 7581 7322 V1/2016
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 Membership no:

Medical Form
Is the applicant, to the best of your knowledge, a likely carrier of any infectious disease, such as
Hepatitis B or C, or the HIV virus? (The applicant does not need to be tested)  Yes  No

Have you noticed any changes in weight or eating habits for the applicant that may give rise to
concern regarding an eating disorder?  Yes  No

Is the applicant currently or has the applicant ever been treated/counseled or received medication
for a nervous condition, eating disorder, depression or emotional problem?  Yes  No

Has the applicant ever been hospitalized or had surgery?    Yes  No

Have you any knowledge that the applicant has ever been a victim of physical, emotional or sexual
abuse?  Yes  No

Is there any history of nervous or emotional problems, depression or abuse (sexual, emotional
or physical) in the applicant's family background?  Yes  No

If you have answered ‘yes’ to any of the above, please provide details including dates, treatment and medication required:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Please use this space to comment on the applicant’s current emotional wellbeing and provide any other relevant information:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

After having reviewed the applicant’s medical notes, please give your opinion on the applicant’s general state of health

Excellent Good Fair Poor

Name of Doctor _________________________________________

Address ______________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Telephone No __________________________________________
Please add your Doctor’s or Medical Practice stamp above

I have examined  and/or reviewed medical notes of  (Tick if applicable) the above named applicant and I find him/her to
be capable of benefitting from and fully participating in an Au Pair in America program.

Do you speak English?  Yes  No If no, did you fully understand all the questions asked on the form?  Yes  No

Signature ____________________________________________________ Date ___________________________________________

37 Queen’s Gate London SW7 5HR UK Tel: +44 (0)20 7581 7322 V1/2016
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