Physicians-Report 7-21-2023

PHYSICIAN’S REPORT
ONLY to be filled out by a licensed health professional
The applicant below has applied to become an au pair in the United States for a minimum of one year. As
a part of acceptance into the program, an established physician must attest to the health of the
applicant. Since the applicant will be spending time with young children, it is important that Agent Au Pair
be advised of any medical conditions, listed or otherwise, that would impair his/her ability to perform in this
capacity in a satisfactory manner. Please answer all questions to the best of your knowledge.
Name of applicant: _____________________________________ Date of Birth: _______________

Has the applicant be under the care of this medical office for at least 5 years? Yes No
Date of exam: ________________ Height: ________________ Weight: ________________
In your opinion, what is the applicant’s general state of health? Excellent Good Fair Poor
Comments: __________________________________________________________________________________
1. Has the applicant ever had (or currently has):
Yes No Yes No
Allergies Anemia
Anorexia Arthritis
Asthma Bulimia
Skin Allergies Depression
Diabetes Dizziness
Heart Disease Malaria
Tuberculosis Ulcers
Hepatitis Headaches
Seizures Currently Pregnant
Other: _____________________________________________________________________________________
2. Surgery and Medication
Has the applicant undergone surgery of any kind? Yes No
If yes, give dates and details (use a separate sheet of paper if necessary): ______________________
______________________________________________________________________________________________
Is the applicant currently taking any medications (other than birth control)? Yes No
If yes, please list: _____________________________________________________________________________
3. Has the applicant ever received treatment for any of the following?
Yes No Yes No
Psychological problems Depression

Anxiety disorder Emotional disorder
Schizophrenia Physical or mental restrictions
Eating disorder Learning disability
I certify that the above information is complete and accurate and all important medical information has
been included.
Physicians Signature & Stamp: ______________________________________ Date: _____________________
Agent Au Pair- Physician’s Report

Version 11-2022 Page 1 of 2
PHYSICIAN’S REPORT
ONLY to be filled out by a licensed health professional
4. Vaccinations:
Yes No
Polio: Date: _________________________________________

Diphtheria: Date: _________________________________________
Measles, Mumps & Rubella: Date: _________________________________________
Other (if applicable- name and dates): _______________________________________________________
5. Are there any abnormalities of the following systems?
Yes No Yes No
Tonsils, nose, throat Neurological
Skin Eye, vision
Cardiovascular Muscular, skeletal
Gastrointestinal Ears, hearing
Metabolic
If yes to any of the above, please give details: _________________________________________________
6. Other Comments:
For any medical conditions checked yes, please briefly explain any continuing problems and how it may
affect the applicants ability to perform the childcare duties of an au pair:
____________________________________________________________________________________________
____________________________________________________________________________________________
Au Pair is physically capable of managing babies/children/ cleaning, which may require lifting/carrying
of items up to 20kilos/45lbs: Yes No
If no, please expalin:_______________________________________________________________________________
Is there any condition to your knowledge that Agent Au pair may want to consider before placing the
applicant in an American home with small children for one year? Yes No
If yes, explain: ____________________________________________________________________________________
____________________________________________________________________________________
Additional comments of physician (attach a separate sheet of paper if necessary):
______________________________________________________________________________________________
________________________________________________________________________________________________
I certify that the above information is complete and accurate and all important medical information has
been included.
Physicians Signature & Stamp: ______________________________________ Date: _____________________
Address: _________________________________________________________ Telephone: _______________
Agent Au Pair- Physician’s Report

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Physicians-Report 7-21-2023

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PHYSICIAN’S REPORT

ONLY to be filled out by a licensed health professional

Name of applicant: _______________________ Date of Birth: _

Psychological problems Depression

Physicians Signature & Stamp: __________________ Date: _

Agent Au Pair- Physician’s Report

Polio: Date: _________________________________________

5. Are there any abnormalities of the following systems?

of items up to 20kilos/45lbs: Yes No

If no, please expalin:_______________________________________________________________________________

If yes, explain: ____________________________________________________________________________________

Additional comments of physician (attach a separate sheet of paper if necessary):

Physicians Signature & Stamp: __________________ Date: _

Address: ___________________________________________ Telephone: _

Agent Au Pair- Physician’s Report

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