Paragraph 2

The Applicant

(If there is more than one applicant, a report on each applicant should be supplied covering all the matters listed below.)

A (i) name, date of birth, sex, weight and height;

(ii)

a family health history, covering the parents, the brothers and sisters and the children of the applicant, with details of any serious physical or mental illness and inherited and congenital disease;

(iii)

marital history, including (if applicable) reasons for inability to have children;

(iv)

past health history, including details of any serious physical or mental illness, disability, accident, hospital admission or attendance at an out-patient department, and in each case any treatment given;

(v)

obstetric history (if applicable);

(vi)

details of any present illness, including treatment and prognosis;

(vii)

a full medical examination;

(viii)

details of any daily consumption of alcohol, tobacco and habit-forming drugs;

(ix)

any other relevant information which might assist the medical adviser; and

(x)

the name and address of any doctor(s) who might be able to provide further information about any of the above matters.

B The signature, name, address and qualifications of the medical practitioner who prepared the report, and the date of the report and of the examination carried out.