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Transcript
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.