Medical Certificate

This document certifies the medical status of an individual based on a professional medical evaluation performed on the date below.

Patient Information

Full Name: {fullName}
Date of Birth: {dateOfBirth}
Gender: {gender}
Identification/Passport Number: {idNumber}

Medical Evaluation

Date of Examination: {examinationDate}
Place of Examination: {examPlace}
Medical Condition: {medicalCondition}
Diagnosis Summary:
{diagnosisDetails}

{#isFit}

Fitness for Work/Study: The patient IS FIT for work/study.

{/isFit}

{^isFit}

Fitness for Work/Study: The patient is currently NOT FIT for work/study.

{/isFit}

{#restrictions}

Specific Restrictions or Recommendations:

• {recommendation}

{/restrictions}

Medical Practitioner

Name: Dr. {doctorName}
Medical License Number: {licenseNumber}
Date of Issue: {issueDate}
Signature: _______________________

Additional Notes

{#notes}

• {noteText}

{/notes}