The United Methodist Church s2

(UPLOAD IN EBRIDGE) THE UNITED METHODIST CHURCH MEDICAL REPORT OF MINISTERIAL CANDIDATE

Mail completed form (Part I and Part II) to: Office of Spiritual Leadership, 320D Briarwood Drive, Jackson, Mississippi 39206

Part I: MEDICAL HISTORY REPORT To be completed by the candidate.

Full Name ______Date of Birth ______Last Frist Middle Address ______Street Apt. # City State Zip

E-mail ______

Marital Status: Single, never married _____ Married in first marriage _____ Married, in second or more _____ Widowed _____ Separated _____ Divorced _____

Number of children ______

1. Check if you have ever had: __ Arthritis __ Diabetes __ High blood pressure __ Poliomyelitis __ Asthma __ Epilepsy __ Kidney trouble __ Rheumatic fever __ Cancer __ Heart trouble __ Peptic ulcer __ Tuberculosis

2. Check if any member of your family:__ Arthritis __ Diabetes __ High blood pressure __ Poliomyelitis __ Asthma __ Epilepsy __ Kidney trouble __ Rheumatic fever __ Cancer __ Heart trouble __ Peptic ulcer __ Tuberculosis

Explain ______

3. What vaccinations or inoculations have you had? Give dates. ______

______

4. Have you ever had an electrocardiogram? If so, give date an attending physician: ______

______

5. Have you ever had a serious accident or operation? Explain. ______

______

6. Have you any impairment of sight? __ Yes __ No Hearing? __ Yes __ No

7. If your weight has changed in the past two years, state approximate loss/gain. ______

8. Have your ever been rejected for life insurance? __ Yes __ No

9. Have your ever received treatment for alcohol or drug habit? ___ Yes __ No

10. Do you smoke? __ Yes __ No If yes, how long? ______How much? ______

11. Have you ever been under observation or treatment in any hospital or sanitarium for a physical or nervous condition? __ Yes __ No Explain ______The above statements are true and accurate to the best of my knowledge.

Signature ______Date ______

PART II: MEDICAL EXAMINER’S REPORT To be completed by the physician.

1. General Appearance ______

2. Personal Hygiene ______

3. Height ______Weight ______

4. Temperature ______Pulse ______Blood pressure ______(Give readings before Temperature ______Pulse ______Blood pressure ______and after exercise)

5. Vision ______

6. Hearing ______

7. Condition of mouth and throat: ______Pharynx ______Tonsils ______Mucous Membranes ______Teeth ______Tongue ______Gum ______

8. Evidence of goiter, enlarged glands, or other tumors ______

______

9. Evidence of varicosity ______Heart ______Lungs ______Thorax ______Spine ______Genitalia ______

10. Evaluate nervous and mental condition ______

______

Laboratory Tests (required) Pap Smear (for all women) ______Mammogram ______PSA (for men over 50) ______Cholesterol ______Fasting Blood Sugar ______

SUMMARY OF FINDINGS AND RECOMMENDATIONS

______

Name of physician (Type or print) ______

Address ______Street City State Zip

Signature of Physician ______

Form 103