To the Physician,

The candidate is applying to a cultural exchange program where he/she will be an au pair and travel to the United
States and live there for 1-2 years. He/she will be responsible for full-time child care for American children in an
American family.

Caring for children can be challenging physically and emotionally and the United States Department of State
requires that all au pairs must be physically and emotionally able to be active and successful participants on the
program.

Important things to remember as you fill in the form:

Please answer every question. Although it may seem irrelevant to this candidate we cannot accept forms
that are not complete.

Please do not include any contraception or birth control information on the form; we do not need this
information.

Immunizations or vaccinations: this section must be completed. We will not accept immunization or
vaccination cards or documents.

The Tuberculosis information is mandatory, and the health evaluation will not be accepted without the
information of this listed on the form.

Please remember to sign, date and stamp the health evaluation and any medical notes provided.

Once you have completed the form please check to see if any of the following are applicable.

Candidate has had surgery or other serious medical treatment.

Candidate will require regular medical attention due to preexisting condition, for example follow
up after surgery

Candidate has history of compulsive, mental, nervous, or stress related issues including sleeping
disorders, etc.

Candidate has had psychological treatment or medication

Candidate has an eating disorder such as anorexia, bulimia etc.

Candidate has at some time taken mood altering medication

Candidate has any illness which is contagious or communicable

Candidate has epilepsy

Candidate has any other disease or abnormality

If any of the above is applicable, you will need to provide a separate medical note. Please briefly describe the
issue/condition; dates (start/end date/ongoing); medication/treatment; outcome of treatment, health today and
how it may impact his/her ability to work as an au pair. Please sign, date and stamp the note.

Thank you for assisting this au pair candidate in the process of becoming an au pair with Cultural Care.

If you have any questions regarding this form please call our office Tel:
The Cultural Care Au Pair team
www.culturalcare.com (should be country specific)
Medical note
The medical note should include the following information and anything other that you think is relevant.

Date of examination
Name of applicant
Diagnosis/symptoms/issue/condition
Dates (month/year of last occurrence)
Treatment/medicine
Outcome of treatment
Health state today
How might this impact the applicants ability to work as an au pair?
Signature, date & stamp of physician