Medical History Questionnaire MEDICAL POINT

Name: If have Social Securtiy Number /TAJ/ or Passport number:

Place of birth: Application ID(LoA):

Date of birth: Name of host institution:

Nationality: Address in Hungary:

Country of origin: E-mail / please fill out exactly and legible /:

The following questions must be answered truthfully and to the best of your knowledge. All information provided
will be treated in the strictest confidence*.
Please complete the following questionnaire by circling or underlining “YES” or “NO” and give a detailed answer to
“If YES, please specify”! Please use capital letters!

Have your parents, brothers or sisters ever had any known illnesses (high blood pressure,
1 diabetes, asthma, bleeding disorders etc.)? YES NO
If YES, please specify:

Do you have any personal history of previous illnesses?

2 YES NO
If YES, please specify:

Have you had any infectious diseases (measles, rubella, mumps, tuberculosis etc.)?
3 YES NO
If YES, please specify:

4 Have you had any operations/surgeries/severe accidents/injuries? YES NO

If YES, please specify:

5 Have you ever tested positive for HIV? YES NO

6 Have you ever tested positive for Hepatitis-B or -C? YES NO

7 Have you ever had seizures or blackouts? If YES, when, and how often: YES NO

Do you have any current illness or chronic disease?

8 YES NO
If YES, please specify:
Do you take any medications on a routine basis?
9 YES NO
If YES, please specify:
Do you have any known allergies (food, insect stings, penicillin, hay fever etc.)?
10 YES NO
If YES, please specify:
Do you have any mental disorder (common crying, depression, prostration, distress, sleep
11 YES NO
disorder etc.)?
12 Do you take drugs other than those prescribed by a doctor? YES NO
sdsd
Medical History Questionnaire MEDICAL POINT

13 Do you consume alcohol? If YES, please specify (seldom/weekly/daily): YES NO

14 Do you smoke? If YES, how many cigarettes per day: YES NO

15 Have you got eyeglasses or contact lenses? Diopter? Right:…………. Left: ………………… YES NO

Do you have any problems with hearing?

16 YES NO
If YES, please specify:
17 Have you been vaccinated against diphtheria, tetanus, acellular pertussis, poliomyelitis? YES NO
18 Have you been vaccinated against measles, mumps, rubella? YES NO
19 Have you been vaccinated against Hepatitis-B? YES NO
20 Have you been vaccinated against typhoid fever? YES NO
21 Have you been vaccinated against HPV (human papillomavirus)? YES NO

22 You are aware of your current pregnancy? YES NO

Do you have any request or information what we have to know?

If YES, please specify:
23 YES NO

I, the undersigned, hereby declare that the above information is true and correct, and that I have answered all the
questions to the best of my knowledge and belief.

Place and date:____________________________

Signature

* Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons
with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC
(GDPR), Act XLVII of 1997 on the processing and protection of health and related personal data, Act CXII of 2011 on the Right to
Information and Self-Determination

sdsd