Medical Application Form - Fillable Page 3
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1
2
3Medical Conditions
Name of applicant
Age:
Sex:
Date of application:
/
/
(dd/mm/yyyy)
Medical condition/diagnosis:
(if more than one sickness, please complete a separate form for each)
Date of last treatment/symptoms:
/
/
(dd/mm/yyyy)
ongoing treatment = current date
Diagnosis Status:
Yes
No
Cured/ no symptoms
Ongoing symptoms
Ongoing hospitalization
Pending hospitalization
Ongoing treatment
Pending treatment
In case of any Diagnosis Status the applicant was treated as:
Outpatient
Hospitalized
Treated both ways
Operated on:
/
/
(dd/mm/yyyy)
How often do the symptoms occur?
or can the illness be described as follows?
Acute
Chronic
Recurrent
Did you have any bone fractures or injuries to bones or tendons?
Has any material used for osteosynthesis etc. been removed?
In case medication is required on a regular basis please specify the genuine name,
the brand name as well as the daily/weekly quantity below.
In case you are suffering from hypertension please specify your Systolic and Diastolic readings below.
Systolic:
Diastolic:
In case of diabetes please specify whether insulin dependent.
Date:
Signature:
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Parent category: Business