PAPUA NEW GUINEA
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DEPARTMENT OF FOREIGN AFFAIRS
IMMIGRATION & CITIZENSHIP DIVISION

MEDICAL EXAMINATION
	For Persons Seeking Permanent Admission to Papua New Guinea
Part A.	DECLARATION BY INTENDING MIGRANT
NAME:……………………………………………………………………………………………………………………………….
					(Full name in BLOCK capitals)
ADDRESS…………………………………………………………………………………………………………………………...

DATE OF BIRTH……………………………………….Identity Document/Passport No……………………………………

1.	Have you, or has any member of your family ever had any serious illness or surgical operation?

If so, give details……………………………………………………………………………………………………………

2.      Have you, or has any member of your family ever suffered from or been suspected of suffering from        
         
tuberculosis?  If so, give details……………………………………………………………………………………………

3.	Have you, or has any  member of your family ever suffered from a nervous or mental disorder, fits or epilepsy,  or been treated in an institution for any kind of these disorders?

If so, give details………………………………………………………………………Examiners initials………………

4.	What medical attention have you required during the last twelve months?

…………………………………………………………………………………………………………………………………..
5.	Do you, or does any member of your family, suffer from any physical disability which will prevent you/him/her from leading a normal life in Papua New Guinea?

If so, give details……………………………………………………………………………………………………………

I hereby CERTIFY that the above statements and all information about myself and my dependants supplied by me to the Medical Examiner are correct in every particular:

	Signature of intending migration…………………………………………………………………………………….
						(To be made in the presence of the Medical Examiner)
Part B.	TO BE COMPLETED BY THE MEDICAL EXAMINER  (All physical signs to be recorded under the various system headings together with an estimate “REMARKS” of any disability caused)

A.	Heart………………………    G.    Skeleton-Bones and Joints	 K.     Genito Urinary Organs………………….

B.     Blood Pressure Syst:…….	     ………………………………	 L.     Urine-Is albumen or

        …………….. Diast:……….   H.     Skin…………………………          sugar present?

C.     Lungs…………………….     I.     Hearing……………………..           ……………………………………………..

D.     Nervous System………..     J.     Sight                                         M.    Teeth………………………………………

E.     Mental conditino and                 (a) Without glasses, R….L… N.     Deformities………………………………

         Intelligence…………….             (b) With glasses (if worn)      O.     If pregnant, period of

F.     Digestive Organs……………                 R…….L…….                          pregnancy………………..………………

Height……………….. Weight……………………….

REMARKS (The Medical Examiner should comment on any departure from normal found or stated) …………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………………………..
	I CERTIFY that I have this day examined the above-named, that the results are as set forth, and in my opinion:
(i)	subject to any special observations under ‘Remarks’, the above-named is in good health and of sound ability to earn a living in Papua New Guinea.
(ii)	The above-named suffers a nervous, mental or physical defect as quoted and/or is NOT in good health.
*Delete whichever does not apply.

						…………………………………Date………………………...
						(Signature and Qualifications)
			
						Address………………………………………………………
Govt.Print – A3918/20 000. – 11.81