Health Declaration
Health Declaration
Health Declaration
Photo
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.
E- mail: _________________________________________
HEALTH CERTIFICATES
BASIC DATA
Name ______________________________
BASIC DATA Passport No. _________________
Age___________ Yrs. Weight in kg: __________ Height in kg: __________ BMI: ________
___________________________________________________________________________.
Country _______________________________
Branch of work: _____________ (Agriculture/ building/ home nursing/ institutional nursing/ hotels)
2 2023 בדיקות רפואיותHealth Declaration
Do you drink, or have you been drinking alcoholic beverages regularly? Please
specify the quantity of consumption: _______ glasses per day
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?
MEDICAL HISTORY
Have you been diagnosed with any illness, syndrome, disorder related to one Yes No
or more of the issues specified below:
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 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 .
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 ________________
_______________________________________________________________
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..………
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.