PROTECTED WHEN COMPLETED - B
PAGE 1 OF 6
MEDICAL REPORT
MEDICAL HISTORY QUESTIONS
UCI number: IME number: UMI number (if applicable)
Family name Given name(s) Date of birth (YYYY-MM-DD)
IF YOUR ANSWER IS YES TO ANY OF THE FOLLOWING QUESTIONS, PLEASE PROVIDE ADDITIONAL INFORMATION INCLUDING:
DIAGNOSIS, DATE, AND TREATMENT (INCLUDING MEDICATIONS AND/OR MAJOR SURGERIES)
MEDICAL HISTORY QUESTIONS RESPONSE ADDITIONAL INFORMATION FOR "YES" RESPONSE ONLY
1. Tuberculosis (TB), treatment for tuberculosis No Yes
2. Close household or work contact with Tuberculosis
No Yes
(CXR will be required for all clients regardless of age)
3. Prolonged medical treatment and/or repeated hospital admissions for any
No Yes
reason, including a major operation or psychiatric illness
4. Psychological/Psychiatric Disorder (including major depression, bipolar
No Yes
disorder or schizophrenia).
5. An abnormal or reactive HIV blood test No Yes
6. An abnormal hepatitis B or hepatitis C blood test No Yes
7. Cancer or malignancy in the last 5 years No Yes
8. Diabetes No Yes
9. Heart condition including coronary disease, hypertension, valve or
No Yes
congenital disease
10. Blood condition (including thalassemia) No Yes
11. Kidney or bladder disease No Yes
12. An ongoing physical or intellectual disability affecting your current or future
ability to function independently or be able to work full-time (including No Yes
autism or developmental delay).
13. An addiction to drugs or alcohol No Yes
14. Are you taking any prescribed pills or medication (excluding oral
No Yes
contraceptives, over-the-counter medication and natural supplements)
15. For female clients:
No Yes
a) Are you pregnant?
b) If yes, what is the expected date of delivery? Date (YYYY-MM-DD)
c) Do you wish to proceed with the required x-ray examination? No Yes
IMM 5419 (07-2018) E
HISTORY (DISPONIBLE EN FRANÇAIS - IMM 5419 F)
PROTECTED WHEN COMPLETED - B
PAGE 2 OF 6
MEDICAL REPORT
PHYSICAL EXAMINATION
UCI number: IME number: UMI number if applicable
Family name Given name(s) Date of birth (YYYY-MM-DD)
FOR ABNORMAL FINDINGS, PLEASE PROVIDE: HISTORY, DIAGNOSIS, TREATMENT DETAILS (INCLUDING DATES AND MEDICATIONS),
LAB RESULTS, SPECIALIST REPORTS (AS REQUIRED), CURRENT STATUS AND PROGNOSIS.
PHYSICAL EXAMINATION RESPONSE COMMENTS ON ABNORMALITIES
Date (YYYY-MM-DD)
Date of examination
16. Was a chaperone offered? No Yes
17. Was a chaperone present? No Yes
18. a) Height
Normal Abnormal
cm Age ≤ 2 Yrs: Percentile
18. b) Weight
Normal Abnormal
kg Age ≤ 2 Yrs: Percentile
The BMI will automatically be For results in 3rd percentile
18. c) BMI calculated by the CIC provide Paediatric report.
electronic system.
The panel physician must enter
BMI (For clients ≥ 18 years) the height in cm
and the weight in kg above.
19. Head Circumference (children ≤ 2 years old)
Normal Abnormal
cm Percentile
20. Ear / Nose / Throat / Mouth Normal Abnormal
21. Hearing Normal Abnormal
22. Eyes (include Fundoscopy) Normal Abnormal
23. Best Distance Visual Acuity Adult Children
(with or without correction)
R Normal
(Possible adult values: 6/6 to 6/60) L Abnormal
24. Blood Pressure
(required for all clients 15 years and older)
Normal Abnormal
Hypertension: ≥ 140 / ≥ 90
Systolic: Diastolic:
IMM 5419 (07-2018) E
PHYSICAL (DISPONIBLE EN FRANÇAIS - IMM 5419 F)
PAGE 3 OF 6
UCI number: IME number: UMI number (if applicable):
Family name Given name(s) Date of birth (YYYY-MM-DD)
25. Cardiovascular System Normal Abnormal
26. Respiratory System Normal Abnormal
27. Nervous System
Sequelae of stroke or cerebral palsy or other neurological Normal Abnormal
disabilities.
28. Mental and Cognitive State Normal Abnormal
29. Intellectual Ability Normal Abnormal
30. Developmental Milestones
Normal Abnormal
(for all clients less than 5 years of age)
31. Gastrointestinal System Normal Abnormal
32. Musculoskeletal Normal Abnormal
33. Skin and Lymph Nodes Normal Abnormal
34. Evidence of substance abuse (e.g., venous puncture marks)
(provide any history of violent behaviour related to substance No Yes
abuse)
35. Breast examination
Normal Abnormal
(where there are concerns regarding changes in breast(s))
36. Endocrine System
Normal Abnormal
(such as evidence of complications from diabetes)
37. Are there any physical or mental conditions which may prevent
this person from attending mainstream school, gaining full No Yes
employment or living independently now or in the future?
IMM 5419 (07-2018) E
PHYSICAL
PROTECTED WHEN COMPLETED - B
PAGE 4 OF 6
MEDICAL REPORT
LABORATORY REQUISITION AND REPORT
UCI number:
IME number PHOTOGRAPH
required for all clients.
Must be taken
UMI number (if applicable): within six months
of the medical
examination.
Family name Given name(s)
Date of birth (YYYY-MM-DD) Country of birth Gender
I have confirmed the BIODATA / Identity of the client ► No Yes
I have concerns about the BIODATA / Identity of the client ► No Yes ► If YES, please provide details:
• Persons collecting blood or receiving specimen should sign or provide name in the corresponding signature/name box to confirm the sample was collected
from the individual identified above.
• Return this form and corresponding lab results/reports to the Panel Physician.
Panel Physician name Panel Physician address Fax number
PLEASE PERFORM THE LABORATORY TESTS INDICATED BELOW
REQUIRED TEST RESULT SIGNATURE OR NAME OF THE PERSON DATE
✔ DESCRIPTION (PLEASE CHECK) COLLECTING THE SAMPLE (YYYY-MM-DD)
Urinalysis Normal
Dipstick Abnormal Blood Protein Glucose
Urinalysis Normal
Microscopy Abnormal (Attach actual laboratory report)
Negative
Syphilis
Positive (Attach actual laboratory report)
Serology
Indeterminate (Attach actual laboratory report)
Negative (Attach actual laboratory report)
HIV
Positive (Attach actual laboratory report)
Serology
Indeterminate (Attach actual laboratory report)
PLEASE ATTACH AN ACTUAL LABORATORY REPORT FOR THE FOLLOWING COMPLETED TESTS, REGARDLESS OF THE RESULT
Serum Creatinine Normal Abnormal
HBsAg Normal Abnormal
Hep C Ab Normal Abnormal
ALT Normal Abnormal
IMM 5419 (07-2018) E
LABORATORY (DISPONIBLE EN FRANÇAIS - IMM 5419 F)
PROTECTED WHEN COMPLETED - B
PAGE 5 OF 6
MEDICAL REPORT
CHEST X-RAY REQUISION AND REPORT
UCI number:
IME number: PHOTOGRAPH
required for all clients.
Must be taken
UMI number: within six months
of the medical
examination.
Family name Given name(s)
Date of birth (YYYY-MM-DD) Country of birth Gender
Date of exam:
Routine PA (posteroanterior) chest X-ray is required. ► (YYYY-MM-DD)
TECHNICIAN/RADIOGRAPHER DECLARATION
I have confirmed the BIODATA / Identity of the client ► No Yes
I have concerns about the BIODATA / Identity of the client ► No Yes ► If YES, please provide details:
Technician/Radiographer signature Date (YYYY-MM-DD)
IMMIGRATION MEDICAL RADIOLOGY GRADING
Please consider the information you have provided about this client. You must consider if there is any evidence of TB or other significant findings. Significant
means that a finding has a current or potential health impact.
A: No evidence of active TB or changes suggestive B: Evidence of active TB or changes suggestive
of other significant diseases identified. of other significant diseases identified.
Comments:
PANEL RADIOLOGIST DECLARATION
I confirm that this immigration radiology examination and report is a true and accurate record of my findings.
Panel Radiologist name Panel Radiologist no.
Panel Radiologist signature Date (YYYY-MM-DD)
IMM 5419 (07-2018) E
CHEST X-RAY (DISPONIBLE EN FRANÇAIS - IMM 5419 F)
PAGE 6 OF 6
UCI number: IME number: UMI number (if applicable):
Family name Given name(s) Date of birth (YYYY-MM-DD)
CHEST X-RAY REPORT
QUESTIONS/FINDINGS RESPONSE DESCRIPTION OF ABNORMAL FINDINGS
Is the client pregnant? No Yes
Date (YYYY-MM-DD)
What is the expected date of delivery?
Has the pregnant woman advised that she wishes to proceed with
No Yes
the required x-ray examination?
Skeleton and soft tissue Normal Abnormal
Cardiac shadow Normal Abnormal
Hilar and lymphatic glands Normal Abnormal
Hemidiaphragms and costophrenic angles Normal Abnormal
Lung fields Normal Abnormal
Evidence of tuberculosis? No Yes
This chest x-ray is suspicious of Active TB No Yes
RECORD OF SPECIAL FINDINGS NOTED ON THE CLIENT'S CHEST X-RAY
FINDINGS GRADE
Single fibrous streak/band/scar 1.1
Bony islets 1.2
Apical pleural capping with a smooth inferior border (< 1 cm thick at all points) 2.1
Unilateral or bilateral costophrenic angle blunting (below the horizontal) 2.2
Calcified nodule(s) in the hilum / mediastinum with no pulmonary granulomas 2.3
Solitary granuloma ( < 1 cm and of any lobe) with an unremarkable hilum 3.1
Solitary granuloma ( < 1 cm and of any lobe) with calcified / enlarged hilar lymph nodes 3.2
Single/multiple calcified pulmonary nodules/micro-nodules with distinct borders 3.3
Calcified pleural lesions 3.4
Costophrenic angle blunting (either side above the horizontal) 3.5
Notable apical pleural capping (rough or ragged inferior border and / or ≥ 1 cm thick at any point) 4.0
Apical fibronodular / fibrocalcific lesions or apical microcalcifications 4.1
Multiple / single pulmonary nodules / micro-nodules (noncalcified or poorly defined) 4.2
Isolated hilar or mediastinal mass / lymphadenopathy (noncalcified) 4.3
Single / multiple pulmonary nodules / masses ≥ 1 cm 4.4
Non-calcified pleural fibrosis and / or effusion 4.5
Interstitial fibrosis / parenchymal lung disease / acute pulmonary disease 4.6
ANY cavitating lesion OR "Fluffy" or "Soft" lesions felt likely to represent active TB 4.7
NONE of the above are present 0
IMM 5419 (07-2018) E
CHEST X-RAY
