<p> (UPLOAD IN EBRIDGE) THE UNITED METHODIST CHURCH MEDICAL REPORT OF MINISTERIAL CANDIDATE</p><p>Mail completed form (Part I and Part II) to: Office of Spiritual Leadership, 320D Briarwood Drive, Jackson, Mississippi 39206</p><p>Part I: MEDICAL HISTORY REPORT To be completed by the candidate.</p><p>Full Name ______Date of Birth ______Last Frist Middle Address ______Street Apt. # City State Zip</p><p>E-mail ______</p><p>Marital Status: Single, never married _____ Married in first marriage _____ Married, in second or more _____ Widowed _____ Separated _____ Divorced _____</p><p>Number of children ______</p><p>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</p><p>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</p><p>Explain ______</p><p>3. What vaccinations or inoculations have you had? Give dates. ______</p><p>______</p><p>4. Have you ever had an electrocardiogram? If so, give date an attending physician: ______</p><p>______</p><p>5. Have you ever had a serious accident or operation? Explain. ______</p><p>______</p><p>6. Have you any impairment of sight? __ Yes __ No Hearing? __ Yes __ No</p><p>7. If your weight has changed in the past two years, state approximate loss/gain. ______</p><p>8. Have your ever been rejected for life insurance? __ Yes __ No</p><p>9. Have your ever received treatment for alcohol or drug habit? ___ Yes __ No</p><p>10. Do you smoke? __ Yes __ No If yes, how long? ______How much? ______</p><p>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.</p><p>Signature ______Date ______</p><p>PART II: MEDICAL EXAMINER’S REPORT To be completed by the physician.</p><p>1. General Appearance ______</p><p>2. Personal Hygiene ______</p><p>3. Height ______Weight ______</p><p>4. Temperature ______Pulse ______Blood pressure ______(Give readings before Temperature ______Pulse ______Blood pressure ______and after exercise)</p><p>5. Vision ______</p><p>6. Hearing ______</p><p>7. Condition of mouth and throat: ______Pharynx ______Tonsils ______Mucous Membranes ______Teeth ______Tongue ______Gum ______</p><p>8. Evidence of goiter, enlarged glands, or other tumors ______</p><p>______</p><p>9. Evidence of varicosity ______Heart ______Lungs ______Thorax ______Spine ______Genitalia ______</p><p>10. Evaluate nervous and mental condition ______</p><p>______</p><p>Laboratory Tests (required) Pap Smear (for all women) ______Mammogram ______PSA (for men over 50) ______Cholesterol ______Fasting Blood Sugar ______</p><p>SUMMARY OF FINDINGS AND RECOMMENDATIONS</p><p>______</p><p>______</p><p>______</p><p>Name of physician (Type or print) ______</p><p>Address ______Street City State Zip</p><p>Signature of Physician ______</p><p>Form 103</p>