MEDICAL STATEMENT

(Confidential Information)

Name, First name Position

Date of birth Gender male/female
Yes No
1. Do you suffer of an illness or exist disturbances or consequences of an accident or a physical
birth defect?
2. Were you unable to work more than 3 weeks because of an illness or accident?
3. Are you taking any medicine on a regular basis?
4. Have you seen a Doctor in the last 3 month?
If you answered any of the 4 questions with yes please give us some details:
Details according to the illness or accident/ Name and Address of the Result 1
Question When How long
Medication taken treating doctor or 2*

* 1 = still under medical treatment

2 = medical treatment finished/healed Yes No
Could you be pregnant?
Are you presently taking prescription medications?
Have you ever had or do you currently have:
Asthma or other breathing problems?

Any allergies? Food related, natural etc?

Frequent sinusitis or bronchitis or lung problems?
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?
Epilepsy, seizures, convulsions or take medications to prevent them?
Recurring complicated migraine headaches or take medications to prevent them?
Blackouts or fainting (full/partial loss of consciousness)?
Frequent or severe suffering from motion sickness (seasick, carsick etc)?
Recurrent back problems? Hernia?
Back, arm or leg problems following surgery?
High blood pressure or take medicine to control blood pressure?
Heart Disease?
Ear diseases or surgery, hearing loss or problems with balance?
Ulcers or ulcer surgery?
Recreational drug use or treatment for, or alcoholism in the past five years?
Thrombosis or similar circulation problem?

I declare, that the information provided in this medical statement and supporting documents is true and correct.
Date: Date:
Signature employee Name, Stamp and Signature Doctor

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