Medical form
 

The purpose of this form is to see whether there are any health problems, which need further attention. Doctors of the SGZ (student healthcare) will check the answers, when necessary an appointment with one of the doctors will be made. Please fill out this medical screening form completely. Your medical history will be completely confidential and will be used to advise you on (preventive) health care.

The fields marked with a * are obliged.

Surname *
First names
Date of birth *
Country of birth *
Date of arrival in Holland *
Address *
City
Postal code
Telephone
GSM (mobile phone)
E-mail
General practitioner in Delft

Do you suffer from:

Diabetes  
High blood pressure/hypertension  
Asthma or bronchitis  
Epilepsy  
Any other chronic disease (if yes please specify below)  
 

Do you suffer from any infectious disease:

tuberculosis  
malaria  
worm infection  
hepatitis B  
HIV/Aids  
other (if yes please specify below)  
 
Do you take any medication? (if yes please specify below)  
 
Have you had any vaccinations? Please specify dates
and vaccins.