1 2023 ‫ בדיקות רפואיות‬Health Declaration

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Name of Medical Facility: _______________________

Country: __________________

Dear doctor,
The applicants intended to work in Israel must be healthy and without disabilities, who have
not suffered in the past from serious, chronic illness or disability. Applicants arriving in Israel
with pre-existing medical conditions or disabilities will not be covered by Israeli medical
insurance. Without insurance, medical costs will be very high; applicants will only be able to
receive emergencies treatment.

Address of medical facility: _____________________________

Phone number of medical facility: _______________________ Fax: _________________

E- mail: _________________________________________

HEALTH CERTIFICATES
BASIC DATA

Ref. No. ___________________ Date of Examination_________/_______/__________

Date Month Year

Name ______________________________
BASIC DATA Passport No. _________________

I.D. No. ____________________ Sex Male Female

Age___________ Yrs. Weight in kg: __________ Height in kg: __________ BMI: ________

Date of Birth ___________/_________/______________ Marriage: Married Single other

Date Month Year

Home Address ________________________________________________________________

___________________________________________________________________________.

Country _______________________________

Branch of work: _____________ (Agriculture/ building/ home nursing/ institutional nursing/ hotels)
2 2023 ‫ בדיקות רפואיות‬Health Declaration

Name ______________________________ Passport No. _________________

General Questions Yes No

Do you use or have you been using narcotics?

Do you drink, or have you been drinking alcoholic beverages regularly? Please
specify the quantity of consumption: _______ glasses per day

Do you suffer from any chronic diseases?

Have you been hospitalized in the last 10 years? Please describe in detail the
reason for hospitalization and the treatment that you have received:
_______________________________________________________________
______________________________________________________.

During the last 10 years, have you been taking, or have you received a
recommendation to take medications regularly? Please describe in details the
problem for which you are treated / have been treated, the treatment, and for
how long have you been taking the medication?
_______________________________________________________________
________________________________________________________.

Have you ever been diagnosed with any allergies in the past?

Please describe in details:______________________

Have you had an accident before?

What extent were you injured in the accident? ___________________

(slightly/moderately/severely injured)

Is your BMI higher than 25?

w Are you pregnant now?

o
m Have you undergone a cesarean delivery in the past?
e
n
3 2023 ‫ בדיקות רפואיות‬Health Declaration

Name ______________________________ Passport No. _________________

MEDICAL HISTORY
Have you been diagnosed with any illness, syndrome, disorder related to one Yes No
or more of the issues specified below:

The nervous system Cerebrovascular accident (stroke) Epilepsy

Multiple sclerosis Muscular dystrophy or other atrophic disease
Reoccurring dizziness Parkinson's syndrome
Alzheimer›s disease Trembling Balance disorders Fainting
Mental retardation Autism Cerebral palsy
Poliomyelitis (infantile paralysis) Gaucher›s disease
1) Loss of sensation (numbness) Migraine
Have you applied to a physician with complaints regarding declined
memory (dementia) AIDS HIV carrier Lupus hypertension
Hemoptysis Edema Yaws Hemorrhoids Fractures
Diabetes mellitus Jaundice Venereal diseases
Acquired Immunodeficiency Syndrome Malaria

Eyes and vision: Cataract Retina and cornea problems Glaucoma

Inflammations of the eye Strabismus Blindness
2)
Other eye disease / problem: No Yes, if ‫ ״‬Yes ‫ ״‬please specify:
____________________
Heart: Cardiac arrhythmias Heart disease Heart failure Heart
attack Congenital heart defect Catheterization
3)
Heart valve diseases, other heart disease / problem: No Yes, if ‫ ״‬Yes ‫״‬
please specify: ____________________
Blood vessels: Varicose vein (in the veins of the legs) Carotid artery (in
the arteries of the neck) Coagulation disorders Blood disease DVT
4)
(Thrombosis) PVD (Peripheral Vascular Disease) other vascular disease /
problem No Yes, if ‫ ״‬Yes ‫ ״‬please specify: ____________________
4 2023 ‫ בדיקות רפואיות‬Health Declaration

Metabolic diseases Thyroid gland Salivary gland Lymph node

Sweat gland Pituitary gland Diabetes Hypertension High levels of
5)
cholesterol/fat, other metabolic disease / problem No Yes, if ‫ ״‬Yes ‫״‬
please specify: ____________________
Respiratory system: Asthma Tuberculosis COPD (chronic
obstructive pulmonary disease) Hay fever Recurrent respiratory
infections and Shortness of breath Collapsed lung (Pneumothorax)
6)
Cystic Fibrosis
Other respiratory system disease / problem No Yes, if ‫ ״‬Yes ‫ ״‬please
specify: ____________________
Digestive system: Ulcer (duodenum / gastric) Crohn's disease
Hemorrhoids Fissure / Fistula Bowel obstruction
Pancreatic diseases / infections Esophagus Gallbladder Gall-
7)
bladder stones
Other digestive system disease / problem No Yes, if ‫ ״‬Yes ‫ ״‬please
specify: ____________________
Liver: Jaundice Hepatitis B, C, D Fatty liver Cirrhosis,
8) Other digestive system disease / problem No Yes, if ‫ ״‬Yes ‫ ״‬please
specify: ____________________
Hernia: Location of the hernia: In the diaphragm / in the navel / in the right
groin / in the left groin
9) Have you undergone a surgery to treat the hernia? No Yes, when
(date)? _____________
Is the problem solved? No Yes
Kidney and urinary tract: Recurrent infections Kidney and urinary
stones Kidney cysts Anomalies of urinary tract Renal failure,
10)
other kidney and urinary tract disease / problem No Yes, if ‫ ״‬Yes ‫״‬
please specify: ____________________
Joints and bones: Arthritis Gout Back / spine Joints Knees
11) Other joints and bones disease / problem No Yes, if ‫ ״‬Yes ‫ ״‬please
specify: ____________________

Skin and sexual diseases Skin tumors Skin lesions Psoriasis

Sexually transmitted diseases Syphilis Gonorrhea
12)
Other skin and sex diseases disease / problem No Yes, if ‫ ״‬Yes ‫ ״‬please
specify: ____________________
Malignant tumors / diseases (cancer): have you suffered from any type
13)
of cancer in the past? Please specify cancer type: ________________
5 2023 ‫ בדיקות רפואיות‬Health Declaration

For women: Gynecological system disease, Breasts (including breast

enlargement)
other feminine problem No Yes
14) Previously had a caesarean section No Yes
If the candidate suffers from any diseases, please specify:
__________________________________________________

For men: Prostate problems Varicocele / Hydrocele

Other masculine disease / problem No Yes, if ‫ ״‬Yes ‫ ״‬please specify:
15)
__________________________________________________

Mental illnesses: Mental illness that was diagnosed by a psychologist,

16) psychiatrist or family physician

Nose, ear or throat diseases: No Yes

17)
Do you suffer from chronic conditions not mentioned in the
18)
questionnaire?

I hereby declare that the above answers are true and complete and given voluntarily,
and that I do not use medication on a daily basis.

I am aware that any material falsification or omission of fact results in my immediate

discharge from my employment in Israel.

I certify that I don't suffer from alcoholism and I am not an alcoholic and I do not
drink alcohol on occasionally nor do I use drugs and I understand, that appearing at
work after use of alcohol or drugs will lead to my discharge from work and
deportation .

Candidate's Signature _____________________ Date_____________

6 2023 ‫ בדיקות רפואיות‬Health Declaration
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Name of Medical Facility: _____________________

Name of Applicant _______________________ I.D. No. _____________________

Passport No ________________________
___________________________________________________________________
____________PHYSICAL EXAMINATION (To be filled in by physician)
Height __________cms. Weight ______ Kgs. Blood Pressure ______ mm. Hg.
Pulse_____/min
Vision: Right ________left _________ Eyes With glasses without
glasses
Color blindness _______________ Blood group ________________
_______________________________________________________________

CHECK EACH ITEM IN APPROPRIATE COLUMN

ITEMS NORMAL ABNORMAL ADDITIONAL COMMENTS

General appearance      
Skin, Scalp   
Lymph nodes     
Eyes     
Ears:      
Otoscopic Exam     
Nose      
Pharynx & Tonsils      
Thyroid gland      
Lungs      
Heart      
Abdomen      
Liver      
Spleen      
Hernia      
External genital      
Rectal exam      
Vertebrae      
Locomotor      
Reflexes      
Mental health status      

Others:
…………………………………………………………………………………………………………………………….…………………………………
7 2023 ‫ בדיקות רפואיות‬Health Declaration

LABORATORY EXAMINATIONS
Hemoglobin ……………………………. Gm% White blood cell count ……………… cells/cu.mm.
Differential: PMN ………. % Lymp ……………% Mono ……………..%Eos ……………………%
Baso …………% Band …………..% Blast ………………. %
Serological test for anti HIV  GPA Test  Positive Negative
Elisa Test Positive Negative
Western Blot Test  Positive Negative
Hepatitis B Surface Antigen Test Positive Negative
A EIA B RIA c  Others..………

Hepatitis C Virus Antibody Positive Negative

Serological test for Syphilis VDRL Test  Positive  Negative

RPR Test  Positive Negative
TPHA Test  Positive Negative

Urine test Test for gonorrhea Positive Negative

Urinalysis: Color………………….Sp. gr……………………….. pH………………….Sugar…………………

Albumin………………………... Blood ………..…... Ketone………………….………..Bile……………………………
Micro: WBC……………/HPF. RBC……………………. /HPF Casts…………. /HPF.
Epithelial Cell…………/HPF. Others……………………………………………………………………………………………………….
Urine pregnancy test (for female only)  Positive Negative

Chest X-ray for tuberculosis  Normal Abnormal

Other examinations: Antihelminth drug receipt on……………………………………………………………….
Tetanus Toxoid 0.5 cc (m) on………………………………………………………….

Summary of Results of Electrocardiogram:

Reason for ending test:
Chest Pain:
Change in ST:
Problems and Summary: ____________________________________________________
8 2023 ‫ בדיקות רפואיות‬Health Declaration

I hereby confirm that after taking the medical history of the applicant,
Name________________ passport No. ___________________ (hereinafter: the
applicant) and examining the results of the above laboratory tests and physical
examination, I have found that the applicant is healthy, does not show signs of alcoholism
or drug abuse, has never in the past suffered from mental illness or severe or chronic
physical illness such as cancer or diabetes, and does not suffer currently from mental
illness or severe or chronic physical illness as above In addition, I confirm that I have found
that the applicant does not suffer from any mental or physical illness or disability, which
requires medication or which would not allow the applicant to carry out full time strenuous
physical work in Israel, including such as heavy lifting, working in the sun or in the rain or
cold etc.

Physician's name _________________________ Signature________________

License No. __________________ Date ____/____/_______