The United Methodist Church s1

FORM103A/2000

THE UNITED METHODIST CHURCH MEDICAL REPORT OF MINISTERIAL CANDIDATE

To the Board of Ordained Ministry: 1. Indicate which laboratory tests your Board requires for completion of the medical examiner’s report. (Lab tests are not required unless deemed necessary by physician)

2. Indicate to the physician the address of the Board officer who will receive this report. Return to : Rev. Janet F. Lord, Registrar Board of Ordained Ministry 783 Freeport Road Creighton, PA 15030 Phone: 412-759-5204 email: [email protected]

Part 1: MEDICAL HISTORY REPORT To be completed by the candidate

Name______Date of birth______

Address______

Marital Status______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 has ever had:

□ 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 and attending physician:______5. Have you ever had a serious accident or operation? Explain______6. Have you any impairment of sight?______Hearing?______7. If your weight has changed in the past two years, state approximate loss______gain______8. Have you ever been rejected for life insurance?______9. Have you ever received treatment for alcohol or drug habit?______10.Do you smoke?______How long?______How much?______11.Have you ever been under observation or treatment in any hospital or sanitarium for a physical or nervous condition? Explain______The above statements are true and accurate to the best of my knowledge Signature______FORM103A/2000

Date______PART II: MEDICAL EXAMINERS REPORT

To be completed by the physician

1.General Appearance______2.Personal Hygiene______3.Height______Weight______4.Temperature______Pulse______BloodPressure______(give readings before and after exercise) 5.Vision______6.Hearing______7.Condition of mouth and throat:______Pharynx______Tonsils______Mucous Membranes______Teeth______Tongue______Gums______8.Evidence of goiter, enlarged glands or other tumors______9.Evidence of varicosity______Hernia______10.Evidence of disease or abnormalities of: Heart______Lungs______Thorax______Spine______Genitalia______11. Evaluate nervous and mental condition______

Laboratory Tests Pap Smear (for all women) ______Mammogram______PSA (for men over 50)______Cholesteral______Fasting blood sugar______

SUMMARY OF FINDINGS AND RECOMMENDATIONS

______

Name of Physician______(Type or print) Address______

Signature of Physician______

Date______

OFFICIAL FORM FROM DIVISION OF ORDAINED MINISTRY