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MEDICAL CERTIFICATE
(as requested for the obtention of a temporary stay permit in Belgium)
I, the undersigned,
after having performed the following examinations :
, doctor in medicine,
General physical examination :
Serological :
Pulmonary radioscopy :
certify that the named :
born in
on
resident on the following address :
does not suffer from any of the diseases or disabilities mentioned hereafter :
a) Diseases that may present a threat to public health :
1. Diseases requiring quarantine :
Cholera, Pest, Smallpox, Yellow Fever.
2. Tuberculosis of the respiratory system, either active of pre-active.
3. Syphilis.
4. Other contagious diseases or parasitical infections (see page 2).
b) Diseases or disabilities that may present a threat to public order or security :
1. Addictions.
2. Marked psychological changes, manifest states of agitated, delirious,
hallucinatory or confused psychosis.
Date :
Signature :
Contagious diseases and diseases transmittable through infection or parasites :
Exanthematic Typhus
Recurent fever
Poliomyelitis (infantile paralysis)
Epidemic influenza
Typhoid fever and paratyphoid fever
Salmonella-infection
Shigelosis
Dyphteria
Scarlatine
Contagious forms of leprosy
Epidemic cerebro-spinal meningitis
Flowing Fever
Infantile streptococcus-infection
Neonatal pemphygia
Neonatal erysypelis
Epidemic infantile diarrhoea
Viral encephalitis
Infectious hepatitis
Rabies (hydrophobia)
Fever, either haemorrhagic or non-haemorrhagic, caused by arbovirus, togavirus,
arenavirus, rhabdovirus, ornithosis, psittacosis, amibiasis and other dysenteries,
gonorrhoea. Nicolas and Favre disease, soft canker, contagious dermatosis,
whooping-cough, mumps, measles, rubella, chicken-pox.