New Zealand Immigration Physical

New Zealand Examination Application

Section A- Personal Details

Write neatly in English using CAPITAL LETTERS. Illegible forms will be returned for clarification.

Question A1 must be completed by the examining physician or delegated staff.

All other questions in this section must be completed by the applicant before the examination.

Write neatly in English using CAPITAL LETTERS.

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Upload Image of your Passport

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Attach one recent passport-size colour photograph of yourself in the space provided. The photograph must be no more than six months old. Write your full name on the back of the photograph. Photograph must be 4.5cm by 3.5cm.

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A1- Examining physician (or delegated staff member): certify identity by placing a signature and date across photograph without obscuring the likeness of the person.

Valid photographic identification sighted? (for example, passport)

A1- Type of identity document:

Original Passport
Certificate of Identity
Refugee Travel Document
National ID Card with Photo

A1- Issuing Country

A1- Identity Document Number

A1- Date of Issue

A1- Date of Expiry

A2- Applicant: name as shown in identity document

Family Name

Given Name

Legal Middle Name On Passport/ID

Title

Select One Choice

Mr
Mrs
Ms
Miss
Dr
Other (Specify)

For Title Answer Other Specify Here

A3- Gender

Select One Choice

Male
Female

A4- Date of Birth (mm/dd/yyyy)

A5- Country of Birth

A6- Contact Address

Unit/Apt #

City

State

Zip

Personal Email Address

A9- How long do you intend to stay in New Zealand:

Select One Choice

Less than 6 months
6-12 months
12-24 months
More than 24 months

Section B- Medical History

Applicant:

You may complete the medical history section yourself and discuss your history with your examining physician, or your examining physician may complete the medical history section with your assistance.
If this health examination is for a child under 18 years of age, the medical history section must be completed by a parent or guardlan, or the examining physician with the assistance of a parent or guardian.
If you answer 'yes' to any question, please give details and give the physician any reports, tests or other information.

Examining Physician:

If the medical history section has been completed before the examination begins, you must confirm each of the answers with the applicant. Do not assume that the applicant has understood the questions.

B1- Have you ever been diagnosed with Tuberculosis (TB)? Have you ever had to take treatment for TB?

Select One Choice

If Yes, Give Details

B2- Have you ever been in close contact at home with a person known to have TB?

Select One Choice

If Yes, Give Details

B3- Have you ever had prolonged medical treatment and/or repeated hospital admissions for any reason, including a major operation or psychiatric illness?

Select One Choice

If Yes, Give Details

B4- Do you suffer, or have you ever suffered, from a psychological or psychiatric disorder (including major depression, bipolar disorder or schizophrenia)?

Select One Choice

If Yes, Give Details

B5- Have you ever had an abnormal or reactive HIV blood test?

Select One Choice

If Yes, Give Details

B6- Have you ever had an abnormal or reactive Hepatitis B or Hepatitis C blood test?

Select One Choice

If Yes, Give Details

B7- Do you have or have you had cancer or malignancy in the last 5 years?

Select One Choice

If Yes, Give Details

B8- Do you have diabetes?

Select One Choice

If Yes, Give Details

B9- Do you have a heart condition including coronary disease, hypertension, valve or congenital disease?

Select One Choice

If Yes, Give Details

B10- Do you have a blood condition (including thalassemia)?

Select One Choice

If Yes, Give Details

B11- Do you have bladder or kidney problems?

Select One Choice

If Yes, Give Details

B12- Do you have an ongoing physical or intellectual disability affecting your current or future ability to function independently or be able to work full-time (including autism or developmental delay)?

Select One Choice

If Yes, Give Details

B13- Do you have an addiction to drugs or alcohol?

Select One Choice

If Yes, Give Details

B14- Are you taking any prescribed pills or medication (excluding oral contraceptives, over-the-counter medication and natural supplements)?

Select One Choice

If Yes, Give Details

B15- Do you have a hereditary or autoimmune condition?

Select One Choice

If Yes, Give Details

B16- Do you have a neurological condition, including having had a stroke or multiple sclerosis?

Select One Choice

If Yes, Give Details

B17- Do you have any significant family health history?

Select One Choice

If Yes, Give Details

Are you pregnant? What is the expected date of delivery?

Select One Choice

If Yes, Give Details

Examining Physician:

I have discussed the applicant's medical history with the applicant (or the applicant's parent or guardian if they are under 18 years of age).

Physician's comments (if any)

Section C- Declaration of person having the medical examination

I undertake to pay the fees for this medical examination including laboratory tests and I also agree that I or my child will undergo, at my expense, any further medical examination(s) that may be required by INZ in respect of the immigration application.

Signature of person being examined

Date of Signature

Signature of parent or guardian if person being examined is under 18 years of age

To accept this contract, type your name below

Date of Signature

Full name of parent or guardian (if applicable)

Relationship to person being examined (if applicable)

New Zealand Immigration Physical

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