Annex No. 5
UNHCR Disabled/Medically-at-Risk Form
Resettlement of Disabled/Medically-at-Risk and Victims of
Torture
Only for completion for those refugees considered in need of
health services available in a resettlement country. To be completed by
examining physician.
1. Recommended for priority action:
|
|
E = Emergency
P = High Priority
L = Low Priority |
2.
Name:__________________________________________________________
Sex:______
Date of Birth:_________________ UNHCR Reg.
No:_____________
Camp:____________________________________________________________
Current
address:____________________________________________________
Date of
examination:________________________________________________
3. Summary
Statement:______________________________________________
4. Medical
History:_________________________________________________
4.1 Pertinent Results of
Investigation/Evaluations:
(i.e. if any blood or urine analysis, ECG,
EEG, X-rays, scanner, etc.)
_________________________________________________________
5. Health
Evaluation:______________________________________________
5.1 Examination
Findings:________________________________________
5.2
Diagnosis__________________________________________________
6. Recommended Treatment Management
Plan________________________
6.1 With Access to Current
Services:________________________________
6.2 With Access to Services
in a Country of
Resettlement:________________
7.
Severity of Condition/Rate of Change/Prognosis:
(i.e.
deterioration/improvement, including anticipated rate of change, life
expectancy) ____________________________________________________
Expected Changes in Health Status/Prognosis
If:
7.1 Remains in
present environment:_____________________________
7.2 Resettles in a third
country:__________________________________
8. Capability to Carry Out Activities of Daily
Living Independently If:
8.1 Remains in present
environment:_____________________________
8.2 Resettles in a third
country:__________________________________
9. Recommendations (include Urgency of
Action):_____________________
10. Other Comments:_____________________________________________
11. Travel - Would the patient need...?
Medical escort: If yes:
Nurse: Doctor:
Wheelchair:
Stretcher:
Medical apparatus on board: Please specify:_____________________
12. Documenting Personnel:
Name:_____________________
Signature:_________________________
Hospital, Clinic,
Agency, Other:
________________________________Date:___________
Name:_____________________
Signature:_________________________
Hospital, Clinic,
Agency, Other:
________________________________Date:___________
