How to Fill Out Physician Medical Report Form

Physician Medical Report Form at a glance

What it is: Physician Medical Report Form: participation in the program is contingent upon CIEE International Study Programs staff receiving a completed medical report from you and your physician.

Who signs: The applicant fills out name, program and signature and then gives the form to the physician, who completes Physician's Name, Physician's Signature, Date, Physician's Address and Physician's Phone Number.

A filled-in Physician Medical Report Form example: an applicant fills out the top of the form

Physician Medical Report Form example filled out, example: an applicant fills out the top of the form
Sam Sample, an applicant, fills out the top of the form. Sam picks the Fall term, then gives the form to a physician. The picture shows that top part, and all its values are invented. Summer, Spring and January/May stay empty in Term(s) because Sam picks only Fall. The physician answers Yes or no questions 6 to 17, so those boxes stay empty. The physician's examination and replies are left blank because the physician gives them. Nothing goes in Physician's name, signature and date because the physician completes that line.

How to fill out Physician Medical Report Form, box by box

Name, program and signature

Physician Medical Report Form example filled out, name, program and signature

Please fill out your name, program and signature and then give this form to your physician.

Term(s) (check all that apply)

Physician Medical Report Form example filled out, term(s) (check all that apply)

Check all that apply under Term(s): Summer, Fall, Spring, January/May, and enter the YEAR.

The physician's examination and replies

Physician Medical Report Form example filled out, the physician's examination and replies

Your doctor should complete this report based on an examination within four months of the program departure date.

Note: It is CIEE's policy not to accept reports filled out by a parent-physician.

It is essential that your replies be based on a current and thorough physical examination and knowledge of the applicant's medical history.

1. How long have you known the applicant? 2. What is the date of the applicant's most current examination? 3. Are you the applicant's family physician, the applicant's College physician or Other? 4. What is the applicant's general state of health: Excellent, Good, Fair or Poor?

5. Please indicate the applicant's vital signs (at rest): a. Pulse Rate, b. Skin, c. Respiration, d. Temperature, e. Blood Pressure.

Yes or no questions 6 to 17

Physician Medical Report Form example filled out, yes or no questions 6 to 17

If the answer to any of the following questions is yes, please give details on a separate sheet. In each case please indicate whether the condition is likely to affect the student's full participation in the program.

YES NO: 6. Is the applicant significantly underweight or overweight? 7. Is the applicant currently taking any medications? 8. Is the applicant allergic to any form of medication?

9. Has the applicant received the following immunizations? If yes, please provide the date of last immunization: a. Diphtheria, Pertussis, Tetanus (DPT), b. Mumps, Measles, Rubella (MMR), c. Polio (Oral or Injectable), d. Hepatitis A, e. Hepatitis B, f. Typhoid, g. Other.

10. Has the applicant ever suffered from asthma or any other respiratory ailment? 11. Is the applicant currently under treatment or observation for any physical or emotional condition? 12. Does the applicant have any speech, hearing, or eyesight impairment that might affect participation in the program?

13. Has the applicant any physical disability that might cause hardship through change of diet, carrying luggage, or strenuous travel? 14. In your judgment will the applicant require assistance from an aide or other second party because of an existing condition at any time on the program?

15. Is there any congenital malformation now existing that may require additional treatment? If yes, what is this congenital condition and what treatment is to be pursued? (Please note that CIEE's insurance coverage does not include treatment of preexisting conditions.)

16. Does this person have a history of emotional disturbance? Has the applicant displayed any of the following? Please explain. a. difficulties in relations with parents, authority figures, peers, b. behavior disorders, c. symptoms such as eating disorders, mood swings, depression, severe sleep disorders, unusual degree of anxiety, fear, or guilt.

17. To your knowledge, are there any predisposing medical, surgical, or emotional factors that may under stress or duress during the program present a need for immediate therapy while abroad? Please explain.

Physician's name, signature and date

Physician Medical Report Form example filled out, physician's name, signature and date

Physician's Name, Physician's Signature, Date, Physician's Address and Physician's Phone Number.

Any additional comments relevant to the patient's physical or psychological condition should be provided on a separate sheet signed and dated by you, the physician.

More rules for Physician Medical Report Form

If you have questions about this form, please contact CIEE at 1-800-407-8839.

Sources

[1] Physician Medical Report Form, CIEE International Study Programs (the Official source link on this page).

What Is the CIEE Physician Medical Report Form?

The CIEE Physician Medical Report Form is a comprehensive health evaluation required for all applicants to CIEE International Study Programs. CIEE support staff and program coordinators use the completed PDF form to review each participant's medical history and confirm medical fitness before the program begins. The form also helps CIEE identify any health-related accommodations that participants may need during the program.

Who Needs to Complete This Form

All students applying to CIEE International Study Programs are required to submit the Physician Medical Report Form. This includes participants in high school exchange programs, college study abroad programs, gap year programs, and professional internship programs operating in the United States and internationally. The application process is not complete until CIEE receives and approves the medical report. Early submission is strongly recommended to avoid delays in program placement and to give CIEE support staff time to review the information.

What the Physician Reviews and Documents

A licensed physician must conduct a full physical examination and complete the physician section of the PDF form. The evaluation covers the applicant's general health status, vital signs, medical history, current medications, and immunization records. The physician must document any physical or psychological conditions that are currently being treated, along with any conditions that could affect the applicant's ability to participate in the international study program. If additional medical information is needed, the physician may attach a separate sheet to the form. The examination must take place within four months of the CIEE program start date, and the completing physician must not be a parent or legal guardian of the applicant.

Submission and Review Process

Once the physician signs and dates the completed form, submit the PDF to your CIEE program coordinator by the specified deadline. CIEE support staff review each submission and contact participants if additional information is needed. Keep a copy of the completed medical report for your personal records. For related health documentation, see our EAEDC Medical Report Form and Student Health Clearance Certificate.

QuestionAnswer
Form NameCIEE Physician Medical Report Form
Form Length1 pages
Fillable?Yes
Fillable fields62
Avg. time to fill out12 min 43 sec
Examination windowWithin 4 months of program start
Other namesphysician's report form, labacorp physician order pdf, medical forms price decrease, ciee medical report

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