Au Pair Medical Record Verification Form

Au Pair Medical Record Verification Form
Applicant’s Name:___________________________________
4450 Arapahoe Ave, Suite 100
Boulder, CO 80303 Date of Birth:_______________________________________
Ph: 720-221-3563
Fax: 720-221-0724 Height (cm):_____________ Weight (kg.):_______________
Instructions: This reference must be completed by a non-relative physician and will be verified by an Au Pair International
representative. You (the physician) will be contacted by the local representative to confirm the information given. All references must
be in English or translated into English with the original document attached.
1. Does the Applicant have any disease or abnormality (please mark N [No] or Y [Yes] for each:
Yes No Eyes or Vision Yes No Locomotors System Yes No Respiratory system
Yes No Ears or Hearing Yes No Bones, Joints Yes No Tonsils, Nose, Throat
Yes No Nervous system Yes No Urine system Yes No Heart, Blood Vessels
Yes No Abdomen Yes No Blood/Endocrine System Yes No Other (please specify)
Please provide detailed information and dates regarding each of the diseases or abnormalities marked Y (yes):
2. Vaccination. Please indicate if the Applicant has been immunized against the following:
Vaccine Yes No Date

Tetanus
Diphtheria
Polio
Measles
Rubella (German measles)
Typhoid
Mumps
Whooping cough
3. Has the Applicant been immunized against tuberculosis with the BCG vaccine: Yes No
4. If the Applicant has not been immunized against tuberculosis with the BCG vaccine, has he/she shown any symptoms of
tuberculosis? Yes No Not Applicable If “Yes” we recommend that the applicant receive immunization.
5. If the Applicant has not been immunized, he/she must pass a TB skin test done within the past year: Not Applicable OR
Skin test date: Test result: Negative Positive
6. Is the Applicant currently suffering from or has he/she ever been treated for:
Depression disorder Yes No Year
Eating Disorder Yes No Year
Personality Disorder Yes No Year
Learning or Speaking Disorder Yes No Year
If answered Yes above, please provide detailed information:
7. Has the Applicant ever been hospitalized (if yes, please specify):
8. Does the Applicant currently suffer from or has he/she ever suffered from any of the following?
Illness: Disorders:
Chicken Pox Yes No Year Allergies* Yes No Year
Measles Yes No Year Asthma* Yes No Year
Mumps Yes No Year Diabetes Yes No Year
Rubella Yes No Year Enuresis Yes No Year
Malaria Yes No Year Gall Stones Yes No Year
Hepatitis Yes No Year Herpes Yes No Year
If yes, what type: ___________________ Parasites Yes No Year
Headaches Yes No Year Seizure disorder Yes No Year
Hyper/Hypothyroidism Yes No Year Dizziness Yes No Year
Hernia Yes No Year
*If yes on allergies or asthma, please fill in an allergy statement and attach it to this document.
Other (please specify):
9. Has the Applicant ever been the victim of sexual, emotional or physical abuse (if yes, please specify): Yes No
10. Does the Applicant have any physical and/or emotional health limitations that would limit her/his participation in
providing healthcare (if yes, please explain)? Yes No
11. Is the Applicant currently taking any medications (please specify): Yes No
12. Is the Applicant allergic to any drugs? (Please list the drugs and their English substitute names): Yes No
13. Other conditions or illness. Is there any other history of physical or emotional related problems or condition which a host family
should take into account when reaching a decision to have the Applicant live in their home and care for their children for one year?
Yes No
14. In your professional opinion, is the Applicant in good health? Yes No
15. In your professional opinion and based on this physical checkup, will the Applicant be fully capable of participating in the
USA Au Pair Program, which includes caring for children 10 hours per day for up to 45 hours per week? Yes No
I, the undersigned, reviewed the medical history of the Applicant and have given a thorough physical
examination. I certify that the above information is complete and accurate, and that all important medical
information has been included in this form.
Daytime telephone:___________________________________ Evening telephone:______________________________________
COUNTRY CODE/AREACODE/LOCAL NUMBER COUNTRY CODE/AREACODE/LOCAL NUMBER
Signature:___________________________________________________________ Date: _____________________________
Physician’s Stamp or Stamp, and Signature:
Office use only: Verified by _____________________________________________________ Date: ___________________

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Au Pair Medical Record Verification Form

Vaccine Yes No Date

If answered Yes above, please provide detailed information:

Other (please specify):

14. In your professional opinion, is the Applicant in good health? Yes No

Signature:_______________________________ Date: _

Physician’s Stamp or Stamp, and Signature:

Office use only: Verified by ___________________________________ Date: _

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