The Medical Self Declaration Form is a crucial document in the Belgian healthcare and regulatory landscape, designed to capture an individual's comprehensive health information in a standardized format. This document is commonly required for various purposes, including employment medical screenings, insurance applications, sports participation, and educational enrollment. The form must comply with Belgian healthcare legislation, including the Patient Rights Act of 2002 and the Belgian Privacy Act of 2018, as well as EU GDPR requirements for handling sensitive medical data. It includes sections for personal information, current health status, medical history, medications, and relevant lifestyle factors. The document must be available in Belgium's official languages (Dutch, French, and German) depending on the region of use, and typically requires the declarant to confirm the truthfulness of the provided information under penalty of law.
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1. Personal Information: Basic identification details including full name, date of birth, national registry number, contact information, and preferred language
2. Declaration Purpose: Clear statement of why this medical declaration is being made and its intended use
3. Current Health Status: General overview of current health condition and any ongoing medical treatments
4. Medical History: Details of significant past medical conditions, surgeries, and treatments
5. Current Medications: List of all current medications, including dosages and frequency
6. Allergies and Reactions: Documentation of known allergies and adverse reactions to medications
7. Family Medical History: Relevant hereditary conditions and significant family medical history
8. Lifestyle Factors: Information about smoking, alcohol consumption, and other relevant lifestyle factors
9. Declaration Statement: Formal statement confirming the truthfulness of provided information
10. Data Protection Notice: GDPR-compliant statement about how the medical information will be processed and protected
1. Pregnancy Status: Section for female patients of childbearing age when relevant to the medical declaration purpose
2. Occupational Health Information: Required when the declaration is for workplace-related purposes
3. Sports Fitness Declaration: Additional section for sports-related medical declarations
4. Mental Health Status: When mental health assessment is relevant to the declaration purpose
5. COVID-19 Status: Information about COVID-19 vaccination and infection history when required
6. Insurance Information: When the declaration is required for insurance purposes
1. Medical History Documentation: Attached copies of relevant medical reports or test results
2. Vaccination Record: Detailed record of vaccinations when required
3. Medication List Details: Comprehensive list of current and recent medications with full details
4. Previous Medical Certificates: Copies of relevant previous medical certificates or declarations
Relevant legal definitions
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Healthcare
Insurance
Human Resources
Occupational Health
Education
Sports and Recreation
Transportation
Aviation
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Construction
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Public Service
Emergency Services
Relevant Teams
Human Resources
Occupational Health
Legal and Compliance
Risk Management
Health and Safety
Employee Relations
Medical Administration
Insurance Operations
Recruitment
Student Affairs
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Human Resources Manager
Occupational Health Physician
Insurance Underwriter
School Administrator
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Safety Officer
Compliance Officer
Medical Administrator
Risk Manager
Employee Relations Manager
Healthcare Facility Manager
Recruitment Specialist
Maritime Officer
Aviation Medical Examiner
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