Medical Self Declaration Form

Medical Self Declaration Form Template for Denmark

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Document background

The Medical Self Declaration Form is a crucial document used across various sectors in Denmark to collect and verify an individual's health information. This form is designed in accordance with Danish healthcare legislation, including the Sundhedsloven and Databeskyttelsesloven, and complies with EU GDPR requirements for handling sensitive personal data. It is typically required in situations where formal declaration of health status is necessary, such as pre-employment screening, insurance applications, participation in sports activities, or admission to educational programs. The form includes comprehensive sections covering personal information, medical history, current health status, and requires formal attestation of truthfulness. Its primary purpose is to ensure that individuals are medically fit for specific activities while protecting both the declarant and the requesting organization.

Suggested Sections

1. Personal Information: Individual's full name, CPR number (Danish personal ID), address, and contact details

2. Purpose Declaration: Statement of why the self-declaration is being made (e.g., employment, insurance, sports participation)

3. Medical History: Current and past medical conditions, surgeries, and ongoing treatments

4. Current Medications: List of all current medications, including prescribed, over-the-counter, and supplements

5. Family Medical History: Relevant hereditary conditions and significant family medical history

6. Lifestyle Information: Information about smoking, alcohol consumption, and physical activity

7. Declaration of Truth: Statement confirming that all provided information is true and complete

8. Data Processing Consent: GDPR-compliant consent for processing personal health information

9. Signature Section: Date, signature fields, and witness requirements if applicable

Optional Sections

1. Specific Health Conditions: Detailed questions about specific conditions relevant to the purpose (used when the form is for specific activities or professions)

2. COVID-19 Declaration: Specific section about COVID-19 exposure and vaccination status (used when required by current health guidelines)

3. Pregnancy Status: Declaration of pregnancy or planned pregnancy (used when relevant to the purpose, such as certain medical treatments)

4. Emergency Contact Information: Contact details for emergency situations (used in forms for ongoing activities or treatments)

5. Healthcare Provider Information: Details of current healthcare providers (used when ongoing medical supervision is relevant)

Suggested Schedules

1. List of Relevant Medical Conditions: Appendix containing a comprehensive checklist of medical conditions to be addressed

2. Privacy Notice: Detailed information about how the medical data will be processed, stored, and protected

3. Guidelines for Completion: Instructions and explanatory notes for filling out the form correctly

4. Required Documentation List: List of additional medical documents that need to be attached if applicable

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