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    Medical History Questionnaire

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    Hare MasterYoda
    This document is a medical history questionnaire for employees relocating to Abu Dhabi with their families. It requests information about medical conditions, medications, drug use and family health issues. It explains that medical tests will be required upon arrival to obtain a visa, and certain medications may not be available. It also states that recreational drug use is illegal and punishable in the UAE. The form collects details about an individual's health and history of illnesses to be kept confidential for school and region assignments.

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    Download as PDF, TXT or read online from Scribd

    Medical History Questionnaire

    Uploaded by

    Hare MasterYoda
    1K views1 page
    This document is a medical history questionnaire for employees relocating to Abu Dhabi with their families. It requests information about medical conditions, medications, drug use and family health issues. It explains that medical tests will be required upon arrival to obtain a visa, and certain medications may not be available. It also states that recreational drug use is illegal and punishable in the UAE. The form collects details about an individual's health and history of illnesses to be kept confidential for school and region assignments.

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    This document is a medical history questionnaire for employees relocating to Abu Dhabi with their families. It requests information about medical conditions, medications, drug use and family health issues. It explains that medical tests will be required upon arrival to obtain a visa, and certain medications may not be available. It also states that recreational drug use is illegal and punishable in the UAE. The form collects details about an individual's health and history of illnesses to be kept confidential for school and region assignments.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    1K views1 page

    Medical History Questionnaire

    Uploaded by

    Hare MasterYoda
    This document is a medical history questionnaire for employees relocating to Abu Dhabi with their families. It requests information about medical conditions, medications, drug use and family health issues. It explains that medical tests will be required upon arrival to obtain a visa, and certain medications may not be available. It also states that recreational drug use is illegal and punishable in the UAE. The form collects details about an individual's health and history of illnesses to be kept confidential for school and region assignments.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    MOE - MEDICAL HISTORY QUESTIONNAIRE FORM

      This form is intended to capture medical information for yourself and any immediate family members who will be accompanying you to Abu Dhabi.
     The information on this form will be treated in confidence and will be taken into consideration while determining school and region assignments.

     Upon your arrival to Abu Dhabi, you will be required to complete a medical test as part of the employment visa processing where you will be tested, amongst
    others, for HIV, Hepatitis, and Tuberculosis. Failure to pass this medical test will result in the immediate termination of the contract.

     Please note that not all prescriptive medication is available in the United Arab Emirates. We would recommend you confirm the availability of any medication
     that you may require before relocating to Abu Dhabi.
     The possession and use of any recreational drugs is prohibited and punishable according to UAE laws.

    General Information
    Name
    Date of Birth
    Statement of Present Health
    Your statement of present health: Excellent Good Fair/Poor (explain)
    Please explain:
    Do you take non-prescriptive drugs routinely? No Yes (specify)
    Please specify:
    Do you take prescriptive drugs routinely? No Yes (specify)
    Please specify:
    Do you take recreational drugs? No Yes (specify)
    Please specify:
    Are you under the care of a physician now? No Yes (specify)
    Please specify:
    Do you have, or have you ever had, any of the following disease/sickness (please check to the right of each item): NS* - Not Sure
    Yes No NS Yes No NS Yes No NS
    High/low blood pressure HIV Epilepsy or fits
    Dizziness/fainting spells Syphilis Car, sea, or air sickness
    Frequent severe headaches Other sexually transmitted Nervous trouble of any sort
    or migraines diseases
    Eye trouble Jaundice or Hepatitis Depression
    Ear, nose, or throat trouble Tuberculosis Anxiety
    Chronic or frequent colds Tumor, growth, cyst, cancer Eating disorder
    Chronic cough Rupture/hernia Sleeping disorder
    Allergies Kidney/bladder trouble Use tobacco
    Asthma Intestinal problem Excessive use of alcohol
    Severe tooth/gum problem Anemia/blood disorder Skin diseases
    Thyroid trouble Gallbladder trouble Joint problems
    Stomach, liver trouble Abnormal chest x-ray Heart by-pass surgery
    Recurrent back pain Heart trouble Currently Pregnant - Months
    Please specify if YES, NS*and others:

    Do you have any visible tattoos or facial piercings?:


    Family Illness: (if your family will be accompanying you to Abu Dhabi)
    Check if your spouse and/or children have:
    Diabetes Heart trouble Allergy
    High/low blood pressure Asthma Mental disorder
    Cholesterol Autism Cancer of:
    Contagious Disease Specify
    Please explain:
    # of sick days per year for the past 2years
    I state that the information provided is true and complete to the best of my knowledge. In addition, I understand that MOE may
    verify information, and that false or misleading answers are cause for rejection of this application or dismissal if employed and
    the full cost of employment has to be paid by the candidate.

    Signature Date

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