PHYSICIAN VERIFIED MEDICAL HISTORY

NOTE TO PHYSICIAN: The person presenting you with this form is applying to be an au pair with AuPairCare. If accepted, he/she will spend a year
with an American family taking care of the familys children and being responsible for them. It is important that the people we entrust with this
responsibility be in good health. Please provide in depth medical history and attach additional documentation if necessary.

Name of Patient: ____________________________________________________ Date of Birth: ______/_____/______ (month/day/year)

Age: ________ Height: ________ Weight: ________

1. Does this patient have or have they ever suffered from or been diagnosed with any of the following? Indicate by checking "Yes" or "No" for each
condition:

Any disease or abnormality of: General health:

Yes No Yes No Yes No Yes No
Meningitis Tonsils, nose or throat Blood or endocrine system Genito-urinary issues
Mumps Bones, joints or locomotive Mental or nervous disorders Is the patient pregnant
Bulimia Rubella Brain or nervous system Does the patient suffer from any allergies
Chicken pox Scarlet fever Ears or hearing Does the patient have any physical disabilities?
Diabetes Serious or persistent cough Eyes or sight Does the patient have any contagious diseases?
Epilepsy Serious or persistent headaches Heart Does the patient have an alcohol or drug dependency?
Hernia Tuberculosis Lungs or respiratory system Does the patient suffer from panic attacks?
HIV/AIDS Typhoid fever Stomach or digestive Does the patient smoke?
Hepatitis Ulcer Other abdominal organs Other: _____________________________
Measles Vertigo/Dizziness

If "Yes" is checked for any of the above conditions, please explain further and provide the year illness(es) occurred. If the exact year is unknown
please provide an approximate year:
________________________________________________________________________________________________________________________________
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2. Please list all adult inoculations/vaccines/immunizations that have been given to this patient and the approximate month and year received:
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________

3. Has this patient ever been hospitalized?

Yes No If yes, please explain: ______________________________________________________________________________________________
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4. Has this patient been treated for a medical condition in the past 2 years?
Yes No If yes, please explain: ______________________________________________________________________________________________
________________________________________________________________________________________________________________________________

5. Does this patient regularly take any medications (excluding birth control)?
Yes No If yes, please explain: ______________________________________________________________________________________________
________________________________________________________________________________________________________________________________

6. Does this patient have any pre-existing or chronic medical conditions (i.e. asthma, arthritis, diabetes, epilepsy, chronic fatigue, etc.)? ?
Yes No If yes, please explain: ______________________________________________________________________________________________
________________________________________________________________________________________________________________________________

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 PHYSICIAN VERIFIED MEDICAL HISTORY
7. Has this patient ever received psychiatric counseling?
Yes No If yes, please explain: ______________________________________________________________________________________________
________________________________________________________________________________________________________________________________

8. Does the patient have any history or symptoms of an eating disorder such as anorexia, bulimia or other similar conditions?
Yes No If yes, please explain: ______________________________________________________________________________________________
________________________________________________________________________________________________________________________________

9. Does the patient have any history or symptoms of nervous, emotional, or mental disorder (i.e. neurosis, nervous breakdown, panic attacks, etc.)?
Yes No If yes, please explain: ______________________________________________________________________________________________
________________________________________________________________________________________________________________________________

10. Has this patient ever been the victim of physical or sexual abuse?
Yes No If yes, please explain: ______________________________________________________________________________________________
________________________________________________________________________________________________________________________________

11. Is there any reason why this patient should not care for children?
Yes No If yes, please explain: ______________________________________________________________________________________________
________________________________________________________________________________________________________________________________

12. Is there anything more you would like to tell us about this patient?
Yes No If yes, please explain: ______________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________

13. In my expert opinion, the general state of the patients health is: Excellent Good Fair Poor

I, the undersigned, have given a thorough physical examination and reviewed the medical history of the patient.
I certify that the above information is complete and accurate to the best of my knowledge.

Physicians Name:______________________________________________________________

Phone Number:________________________________________________________________ Place Physician Stamp Here

Signature:_____________________________________________________________________

Date:________/________/________ (month/day/year)

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Revised 2/20/2015