Download AGENCIA DE COOPERACIÓN INTERNACIONAL DE CHILE

CHILEAN INTERNATIONAL COOPERATION AGENCY
SCHOLARSHIP PROGRAM OF HORIZONTAL COOPERATION
NELSON MANDELA
CALL FOR APPLICATIONS 2015
ANNEX 6
HEALTH DECLARATION OF THE APPLICANT
All Applicants must submit a Compatible Health Certificate issued and signed by an
authorized medical practitioner.
For this purpose and in accordance with the requirements set forth in the call for
applications for 2015, it is recommended to incorporate the following information in the
declaration of health and preexisting diseases.
1. General Background:
Full Name:
Address:
Country:
Phone Number:
National Identification Marital Status:
Number:
Date of Birth:
Age:
Gender:
Profession:
Height / Size:
Weight:
Pulse:
Blood Pressure:
Other:
2. Medical History:
Current physical fitness:
Medical
history
pathologies):
Comments:
(surgeries, Comments:
1
Family History (Diabetes, epilepsy, Comments:
asthma, hypertension, heart disease,
others).
3. History of general physical fitness:
Head and Neck
Eyes
Visual Acuity
ENT
Auditory Acuity
Pharynx
Thorax
Cardiorespiratory
Abdomen
Genitourinary
Extremities
Osteomuscular system
Nervious system
F.P.A.
Endocrine System
Skin Condition
Laboratory
Tests
(attach originals)
Serology
Smear
Pregnancy Test
Hemoclassification
Normal
Anormal
Date:
Results:
Complete Blood
Count
2
Comments
Uryanalisis
The Applicant is
Suitable:
Unsuitable:
The
undersigned
medical I hereby certify that the provided
practicioner satisfactorily checked information is true. Its inaccuracy
the requested exams.
will lead to rejection.
Doctor’s Signature:
Applicant’s Signature:
Reference Nº:
Identification Number:
Date:
Date:
3