Anmeldeunterlagen Au Pair England - Auszeit-weltweit
Anmeldeunterlagen Au Pair England - Auszeit-weltweit
Anmeldeunterlagen Au Pair England - Auszeit-weltweit
Erfolgreiche ePaper selbst erstellen
Machen Sie aus Ihren PDF Publikationen ein blätterbares Flipbook mit unserer einzigartigen Google optimierten e-Paper Software.
Ärztliches Attest / Medical report<br />
Name und Adresse des behandelnden Arztes<br />
Name and address of the attending doctor<br />
......................................................... ....................................................................<br />
.............................................................................................................................<br />
.............................................................................................................................<br />
.............................................................................................................................<br />
Name der Patientin / des Patienten:<br />
.............................................................................................................................<br />
Geburtsdatum / Date of birth:<br />
......................................................... ....................................................................<br />
Größe und Gewicht der Patientin / des Patienten<br />
Height and weight of the patient:<br />
.............................................................................................................................<br />
Wie lange kennen Sie die Patientin / den Patient?<br />
How long have you known the patient?<br />
......................................................... ....................................................................<br />
Wie ist die generelle gesundheitliche Verfassung der<br />
Patientin / des Patienten?<br />
How would you describe the physical condition of the<br />
patient?<br />
[ ] sehr gut [ ] gut [ ] ausreichend [ ] schlecht<br />
very good good sufficient poor<br />
Leidet die Patientin / der Patient unter chronischen<br />
Krankheiten? Falls ja, unter welchen?<br />
Does the patient suffer from any chronic diseases?<br />
.............................................................................................................................<br />
.............................................................................................................................<br />
.............................................................................................................................<br />
.............................................................................................................................<br />
© 2011 <strong>Au</strong>szeit Weltweit<br />
Stand: 10.2011<br />
1 / 1<br />
Does the patient suffer from any infectious disease?<br />
.............................................................................................................................<br />
.............................................................................................................................<br />
......................................................... ....................................................................<br />
......................................................... ....................................................................<br />
.............................................................................................................................<br />
Benötigt die Patientin / der Patient regelmäßig Medikamente?<br />
Falls ja, welche?<br />
Does the patient needs to take medicine on a regular<br />
basis?<br />
.............................................................................................................................<br />
.............................................................................................................................<br />
......................................................... ....................................................................<br />
......................................................... ....................................................................<br />
.............................................................................................................................<br />
War die Patientin / den Patient jemals in psychologischer<br />
Behandlung?<br />
Has the patient ever received psychological treatment?<br />
.............................................................................................................................<br />
.............................................................................................................................<br />
.............................................................................................................................<br />
......................................................... ....................................................................<br />
.............................................................................................................................<br />
Bestehen aus ärztlicher Sicht Bedenken gegen einen <strong>Au</strong><br />
<strong>Pair</strong> <strong>Au</strong>fenthalt im <strong>Au</strong>sland? Falls ja, erläutern Sie bitte.<br />
Are there any medical reasons against an au pair stay<br />
abroad?<br />
.............................................................................................................................<br />
.............................................................................................................................<br />
.............................................................................................................................<br />
.............................................................................................................................<br />
.............................................................................................................................<br />
Leidet die Patientin / der Patient unter einer ansteckenden<br />
Krankheit? Falls ja, unter welcher?<br />
.............................................................................................................................<br />
Datum, Ort Unterschrift und Stempel des Arztes
Change language