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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:

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:___________