Certificate of Health PDF
Certificate of Health PDF
Certificate of Health PDF
Name:
Family Given Middle
Address:
Street / Postal Box
The candidate named above has applied for participation in an Au Pair Exchange Visitor Program in the United States
of America through an international exchange organization dedicated to fostering cultural enrichment and intercultural
understanding through youth exchange programs. If accepted for program participation, the applicant will spend a year
living with an American host family, joining in their home life, providing child care assistance (45 hours each week),
and attending a U.S. post-secondary educational institution. U.S. government regulations require au pair exchange
program participants to demonstrate that they are fully capable of participating in this program.
HAS THE APPLICANT BEEN TREATED BY A PHYSICIAN, PSYCHIATRIST, PSYCHOLOGIST, OR COUNSELOR FOR:
YES NO YES NO
SCHIZOPHRENIA EATING DISORDER
DEPRESSION PERSONALITY DISORDER
MANIC DEPRESSIVE DISORDER POST TRAUMATIC STRESS
ANXIETY DISORDER LEARNING DISABILITY
HYPERACTIVITY / ATTENTION DEFICIT DISORDER CONDUCT DISORDER
Please give full information (including dates and details) about every disease or impairment mentioned (“Yes“ response)
for any of the above questions:
04/08 1
Name: ID Number:
Are pupillary and knee reflexes normal? Yes No If no, please explain:
Does the applicant have any allergies or dietary restrictions? Yes No If yes, please describe them and
explain how the applicant can/would deal with them in a host family setting?
Has the applicant ever been hospitalized? Yes No If yes, please give date(s), diagnosis and outcome.
Is there a history of child abuse in the applicant’s family? Yes No If yes, please explain:
Does the applicant have any health limitations (physical or emotional) or do you know of any pertinent information that
is important for the Program to know that would limit her / his participation in normal school, family, sports or
community life, including providing child care assistance for an American host family? Yes No
If yes, please explain:
Is the applicant currently receiving any injections or taking any medication? Yes No If yes, please give
name(s) of medication(s) and injections and diagnosis.
Will the applicant require any orthodontic care during the coming year? Yes No If yes, attach a
statement from the orthodontist, indicating present status, exact care essential to the orthodonture and date care will be
completed. (Orthodontic work may not be covered under the Program’s Medical Insurance.)
2
Name: ID Number:
If the applicant is female, does she have any problems in connection with her menstruation? Yes No
If yes, please explain how this affects her normal activities.
Diphtheria
1 2 3 4 5
Pertussis
1 2 3 4 5
Mumps
1 2 3 4 5
Rubella
1 2 3 4 5
Measles (Rubeola)
1 2 3 4 5
Tuberculosis (Mantoux
Test or BCG Test) 1 2 3 4 5
Hepatitis B
1 2 3 4 5
Smallpox
1 2 3 4 5
Typhoid
1 2 3 4 5
Cholera
1 2 3 4 5
Yellow Fever
1 2 3 4 5
Other
1 2 3 4 5
Other
1 2 3 4 5
3
Name: ID Number:
In my professional opinion the general state of the applicant’s health is: (check one)
Comments:
I hereby certify that, to the best of my knowledge, the above information is true and correct.
Address