PHYSICIAN'S MEDICAL REPORT Protected when completed.
Your patient has been selected to be part of a Government of Canada (GoC) overseas event.
The schedule of events is usually quite demanding for which delegates must meet certain requirements in physical capacity. Furthermore, air travel generally induces a certain degree of arterial oxygen desaturation which may have adverse consequences in patients with pulmonary, cardiac, cerebrovascular disease or those with anemia.
Would you be so kind as to assess his/her medical condition with respect to participating in this event. Your evaluation will help us to better understand his/her needs and enable us to provide the appropriate care. It is important to assess every element of this evaluation. Please note that any medical condition must be stable for at least three months prior to departure. Delegate's Authorization
I authorise the release of medical information pertaining to me to Veterans Affairs Canada to be used to assess my physical and mental capabilities to attend a GoC overseas event.
Physically and mentally fit to be able to participate in this event which involves long travel days and considerable walking.
The information you provide on this form is collected under the authority of the Privy Council Order 1965-688 for thepurpose of assessing the physical and mental capabilities of a delegate wishing to attend an overseas event. Provisionof the information is voluntary.
The personal information on this form is protected under the Privacy Act. The recorded opinion about an individual isconsidered personal information about and belonging to that individual. The Privacy Act provides individuals with aright to access their personal information which is under the control of the Department. The Privacy Act also affordsindividuals the right to challenge the accuracy and completeness of their personal information and have it amended asappropriate.
For information on how Veterans Affairs Canada protects your personal information, please contact the Acess to Information and Privacy Coordinator's Office, Veterans Affairs Canada, PO Box 7700, Charlottetown, PE, C1A 8M9.
Ce formulaire est disponible en français. Protected when completed. PLEASE PRINT Stable for 3 months? Medication Medical Condition
- Please send a copy of the pertinent test results (e.g., ECG, X-rays, etc.). - If the patient is taking warfarin please send the INR (done a maximum of 4 weeks prior to the trip). - If the patient has lung disease, please indicate arterial oxygen saturation (oximetry). - If the patient has anemia or polycythemia, please indicate latest hemoglobin level. - If the patient has past history of venous thromboembolic event or pneumothorax, please indicate it in the
*Note - If there are any changes in the medical condition, the GoC delegation medical officer must be advised.* Functional Status: Cognitive Function:
Dr Peter Kiehlmann Dr Christine Paterson Dr Ade Ogunnupe Dr Damian McGrory Working together, caring for your health Assistants Dr Rhona McKeown Dr Julie Cooper Danestone Medical Practice Fairview Street, Danestone, Aberdeen AB22 8ZP Telephone: (01224) 822866 Fax: (01224) 849699 TRAVEL CLINIC QUESTIONNAIRE NOTE: Complete 1