<p> FORM103A/2000</p><p>THE UNITED METHODIST CHURCH MEDICAL REPORT OF MINISTERIAL CANDIDATE</p><p>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)</p><p>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]</p><p>Part 1: MEDICAL HISTORY REPORT To be completed by the candidate</p><p>Name______Date of birth______</p><p>Address______</p><p>Marital Status______Number of children______</p><p>1.Check if you have ever had:</p><p>□ Arthritis □ Diabetes □ High blood pressure □ Poliomyelitis</p><p>□ Asthma □ Epilepsy □ Kidney trouble □ Rheumatic fever</p><p>□ Cancer □ Heart trouble □ Peptic ulcer □ Tuberculosis</p><p>2.Check if any member of your family has ever had:</p><p>□ Arthritis □ Diabetes □ High blood pressure □ Poliomyelitis</p><p>□ Asthma □ Epilepsy □ Kidney trouble □ Rheumatic fever</p><p>□ 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</p><p>Date______PART II: MEDICAL EXAMINERS REPORT</p><p>To be completed by the physician</p><p>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______</p><p>Laboratory Tests Pap Smear (for all women) ______Mammogram______PSA (for men over 50)______Cholesteral______Fasting blood sugar______</p><p>SUMMARY OF FINDINGS AND RECOMMENDATIONS</p><p>______</p><p>______</p><p>______</p><p>______</p><p>Name of Physician______(Type or print) Address______</p><p>Signature of Physician______</p><p>Date______</p><p>OFFICIAL FORM FROM DIVISION OF ORDAINED MINISTRY</p>
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