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    ﻧﻤﻮذج ﻃﻠـﺐ اﻟﻔﺤﺺ الطبي

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    Hisham Mohamed
    This document is a medical examination application form that collects personal details, medical information, and examination results for a candidate. It requests information such as the candidate's name, age, job, gender, medical history, and results from examinations of eyesight, chest, heart, blood pressure, nervous system, hernias, disabilities, urine, stool, and venereal diseases. The form must be signed by three doctors, including the committee chairman, and is void if altered after printing.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    ﻧﻤﻮذج ﻃﻠـﺐ اﻟﻔﺤﺺ الطبي

    Uploaded by

    Hisham Mohamed
    18 views2 pages
    This document is a medical examination application form that collects personal details, medical information, and examination results for a candidate. It requests information such as the candidate's name, age, job, gender, medical history, and results from examinations of eyesight, chest, heart, blood pressure, nervous system, hernias, disabilities, urine, stool, and venereal diseases. The form must be signed by three doctors, including the committee chairman, and is void if altered after printing.

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    This document is a medical examination application form that collects personal details, medical information, and examination results for a candidate. It requests information such as the candidate's name, age, job, gender, medical history, and results from examinations of eyesight, chest, heart, blood pressure, nervous system, hernias, disabilities, urine, stool, and venereal diseases. The form must be signed by three doctors, including the committee chairman, and is void if altered after printing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    18 views2 pages

    ﻧﻤﻮذج ﻃﻠـﺐ اﻟﻔﺤﺺ الطبي

    Uploaded by

    Hisham Mohamed
    This document is a medical examination application form that collects personal details, medical information, and examination results for a candidate. It requests information such as the candidate's name, age, job, gender, medical history, and results from examinations of eyesight, chest, heart, blood pressure, nervous system, hernias, disabilities, urine, stool, and venereal diseases. The form must be signed by three doctors, including the committee chairman, and is void if altered after printing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    ‫ﻧﻤﻮذج ﻃﻠــﺐ اﻟﻔﺤـــﺺ اﻟﻄــــﺒﻲ‬

    ‫ﺻــــﻮرة‬

    Medical Examination Application Form


    Photo

    Personal Details ‫اﻟﺒﻴﺎﻧﺎت اﻟﺸﺨﺼﻴﺔ‬

    Age: :‫اﻟﺴـــﻦ‬ Name: :‫اﻻﺳﻢ‬

    No. Facility: :‫رﻗﻢ اﻟﻤﻨﺸﺎة‬ Facility Name: :‫اﺳﻢ اﻟﻤﻨﺸﺄة‬

    Candidate's Job: :‫اﻟﻮﻇﻴﻔﺔ اﻟﻤﺮﺷﺢ ﻟﻬﺎ‬ Gender: :‫اﻟﺠﻨﺲ‬

    Employer’s Details ‫ﺑﻴﺎﻧﺎت ﺟﻬﺔ اﻟﻌﻤﻞ‬


    Establishment or Responsible Manager Name: :‫اﺳــــﻢ ﺻﺎﺣﺐ اﻟﻤﻨﺸﺄة أو اﻟﻤﺪﻳﺮ اﻟﻤﺴﺆول‬

    Signture: :‫اﻟﺘﻮﻗﻴﻊ‬

    Stamp ‫اﻟﺨﺘﻢ‬

    Medical Information ‫اﻟﻤﻌﻠﻮﻣﺎت اﻟﺼﺤﻴﺔ‬


    Left Eye: :‫اﻟﻌﻴﻦ اﻟﻴـﻤﻨـﻰ‬

    Right Eye: :‫اﻟﻌﻴـــﻦ اﻟﻴـﺴﺮى‬


    Power of Sight ‫ﻗـﻮة اﻹﺑﺼﺎر‬
    Highlight Colors: :‫ﺗﻤﻴـﻴﺰ اﻷﻟﻮان‬

    Notes: :‫اﻟﻤــﻼﺣـﻈـﺎت‬

    Clenic Examination: :‫اﻟﻔﺤﺺ اﻟﻜﻠﻴﻨﻜﻲ‬


    Chest: ‫اﻟﺼـــﺪر‬
    Radiography: :‫اﻟﻔﺤـﺺ ﺑﺎﻷﺷﻌـﺔ‬

    Heart: :‫اﻟﻘﻠﺐ‬

    Blood Blood Pressure: :‫ﺿﻐﻂ اﻟﺪم‬


    Circulation
    ‫اﻟـﺪورة اﻟـﺪﻣﻮﻳـﺔ‬
    Arteries :‫اﻟﺸﺮاﻳﻴﻦ‬

    Veins status: :‫ﺣﺎﻟﺔ اﻷوردة‬

    Nervous System ‫اﻟﺠﻬﺎز اﻟﻌـﺼـﺒﻲ‬

    Hernia ‫اﻟـﻔـﺘـﻖ‬

    Disabilities ‫اﻟـﻌـﺎﻫـﺎت‬

    Urine Diabetes: :‫اﻟﺴـﻜﺮ‬


    Examination ‫ﻓﺤـﺺ اﻟـــﺒﻮل‬
    Albumin: :‫اﻟﺰﻻل‬

    Stool
    Examination If necessary ‫إذا ﻟﺰم اﻷﻣﺮ‬ ‫ﻓـﺤـﺺ اﻟــﺒـﺮاز‬
    Bright blood
    Examination If necessary ‫إذا ﻟﺰم اﻷﻣﺮ‬ ‫ﻓﺤﺺ اﻟﺪم اﻟﺰاﻫﻲ‬
    Venereal
    ‫اﻷﻣﺮاض اﻟﺘﻨﺎﺳﻠﻴﺔ‬
    Diseases

    Final Result ‫اﻟـﻨﺘﻴﺠﺔ اﻟـﻨﻬﺎﺋﻴﺔ‬

    * This form is considered void in case of any scratch or change after printing. ً
    .‫ﻻﻏﻴﺎ ﻓﻲ ﺣﺎل أي ﺷﻄﺐ أو ﺗﻐﻴﻴﺮ ﺑﻌﺪ اﻟﻄﺒﺎﻋﺔ‬ ‫* ﻳﻌﺘﺒﺮ ﻫﺬا اﻟﻨﻤﻮذج‬
    Signatures
    Approvals ‫اﻟﺘﻮﻗﻴﻌﺎت‬
    ‫اﻻﻋﺘﻤﺎدات‬
    Committee Chairman ‫رﺋﻴﺲ اﻟﻠﺠﻨﺔ‬ Doctor 2 2 ‫ﻃﺒﻴﺐ‬ Doctor 1 1 ‫ﻃﺒﻴﺐ‬

    Date: :‫اﻟﺘﺎرﻳﺦ‬ Date: :‫اﻟﺘﺎرﻳﺦ‬ Date: :‫اﻟﺘﺎرﻳﺦ‬

    Stamp ‫اﻟﺨﺘﻢ‬

    * This form is considered void in case of any scratch or change after printing. ً
    .‫ﻻﻏﻴﺎ ﻓﻲ ﺣﺎل أي ﺷﻄﺐ أو ﺗﻐﻴﻴﺮ ﺑﻌﺪ اﻟﻄﺒﺎﻋﺔ‬ ‫* ﻳﻌﺘﺒﺮ ﻫﺬا اﻟﻨﻤﻮذج‬

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