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    Medical Form

    Uploaded by

    Brury Banget
    The document is a medical history form for students applying to study abroad programs at the Hebrew University of Jerusalem. It requests information about the applicant's medical conditions, treatments, hospitalizations, mental health history, allergies and COVID-19 vaccination status. The applicant must certify that the information is complete and accurate, and understand they may need to return home or pay medical costs for pre-existing conditions not disclosed. The applicant's physician also needs to evaluate their general health and sign the form to confirm the applicant is physically qualified to participate.

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    Medical Form

    Uploaded by

    Brury Banget
    27 views2 pages
    The document is a medical history form for students applying to study abroad programs at the Hebrew University of Jerusalem. It requests information about the applicant's medical conditions, treatments, hospitalizations, mental health history, allergies and COVID-19 vaccination status. The applicant must certify that the information is complete and accurate, and understand they may need to return home or pay medical costs for pre-existing conditions not disclosed. The applicant's physician also needs to evaluate their general health and sign the form to confirm the applicant is physically qualified to participate.

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    The document is a medical history form for students applying to study abroad programs at the Hebrew University of Jerusalem. It requests information about the applicant's medical conditions, treatments, hospitalizations, mental health history, allergies and COVID-19 vaccination status. The applicant must certify that the information is complete and accurate, and understand they may need to return home or pay medical costs for pre-existing conditions not disclosed. The applicant's physician also needs to evaluate their general health and sign the form to confirm the applicant is physically qualified to participate.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    27 views2 pages

    Medical Form

    Uploaded by

    Brury Banget
    The document is a medical history form for students applying to study abroad programs at the Hebrew University of Jerusalem. It requests information about the applicant's medical conditions, treatments, hospitalizations, mental health history, allergies and COVID-19 vaccination status. The applicant must certify that the information is complete and accurate, and understand they may need to return home or pay medical costs for pre-existing conditions not disclosed. The applicant's physician also needs to evaluate their general health and sign the form to confirm the applicant is physically qualified to participate.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    THE HEBREW UNIVERSITY OF JERUSALEM

    ROTHBERG INTERNATIONAL SCHOOL

    Medical History Form

    Dear Student,

    We welcome you to HUJI.

    In order to be able to provide you with an ultimate service upon your stay at HUJI, please fill out the following
    health declaration that will help us know your needs and prepare to meet them. This information will stay
    confidential.
    Your health declaration is an essential part of the application for participation in study abroad programs at the
    Hebrew University. Please answer all question below and be in touch with your physician.

    Name of Applicant Social Security Number


    Please indicate the program to which you are applying
    Address
    E-mail Address

    Date of Birth_ Age Gender

    Please answer the following questions in detail:

    1. Is there a medical condition of any kind that may affect your daily routine in any way?
    - No
    - Yes, please specify:

    2. Are you currently undergoing medical treatment or taking medication regularly (including psychiatric
    medications)?
    - No
    - Yes, please specify the medication name and what it is for:

    3. Have you ever been hospitalized or undergone any kind of surgery?


    - No
    - Yes, please specify:

    4. Do you have a history of psychiatric care?


    - No
    - Yes, please explain and provide dates:

    5. Are you allergic to any food or medication?


    - No
    - Yes, please specify:
    6. Are you vaccinated against Covid-19?
    - No
    • I am planning to get vaccinated before my arrival.
    • I am planning to get vaccinated in Israel.
    • I am not sure whether to get vaccinated.
    - Yes

    7. Are you a recovered patient of Covid-19?


    - No
    - Yes

    APPLICANT’S STATEMENT

    I hereby certify that, to the best of my knowledge, this health declaration form is complete in all its details and I fully
    realize that any condition, mental or physical, that I am found to have, originating prior to my arrival in Israel, and
    which is not described in full in this form or in any accompanying letter, will be due cause for my return to my
    country of origin, or treatment in Israel solely at my expense, and that the Program has neither responsibility nor
    liability arising out of such condition.

    I will update the HUJI International staff if any change occurs during my stay in the program.

    Date: Signature:

    To be answered by your Physician

    What is your evaluation of the applicant’s general health and emotional stability (bearing in mind the various
    conditions imposed by a foreign study program: Permanent use of Medicines, lengthy absence from home,
    adjustment to a foreign culture, different living conditions, etc.) ?
    The patient is in good health

    PLEASE VERIFY THAT ALL QUESTIONS HAVE BEEN ANSWERED BEFORE SIGNING BELOW

    Physician's Statement (signed and stamped):

    I have examined the above-named applicant and consider him/her physically qualified to participate in study
    at the Hebrew University.

    Name of Physician (please type or print) dr. Lily Irma Sartika Gala
    Address Jl Mogandi XII, No.3, Kelurahan Malalayang Satu, Manado, Sulawesi Utara

    Signature of Physician
    Telephone +6282296053484 License No. 211003/09/SIP.dr/DINKES/MS/I/2021
    Date 18 May 2023

    Pleas scan and upload the completed form to


    https:/overseas2.huji.ac.il/studentdata/uploadf
    ile.aspx

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