The Medical Self Declaration Form is a crucial document used in the Philippines to gather and verify an individual's health information for various official purposes. This form became particularly significant following the implementation of the Data Privacy Act of 2012 and has evolved to meet modern healthcare documentation requirements. It is commonly required during pre-employment processes, school admissions, insurance applications, and travel clearances. The form typically includes sections covering personal information, current health status, medical history, and specific health declarations as required by Philippine regulations. The document must comply with local healthcare privacy laws while providing necessary medical information to relevant authorized parties.
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1. Personal Information: Basic details including full name, date of birth, gender, civil status, contact information, and government-issued ID numbers
2. Emergency Contact Details: Information about primary and secondary emergency contacts
3. Current Health Status Declaration: General statement about current health condition and any immediate health concerns
4. Medical History: Previous illnesses, surgeries, hospitalizations, and chronic conditions
5. Family Medical History: Hereditary conditions and significant family health issues
6. Current Medications: List of all current medications, supplements, and treatments
7. Allergies and Reactions: Documentation of known allergies to medications, food, or environmental factors
8. Lifestyle Factors: Information about smoking, alcohol consumption, exercise habits, and dietary restrictions
9. Declaration of Truth: Legal statement confirming all provided information is true and accurate
10. Consent and Data Privacy: Agreement to information sharing and acknowledgment of data privacy rights under RA 10173
1. COVID-19 History: Section for vaccination status and previous COVID-19 infections, to be included during pandemic-relevant periods
2. Mental Health Declaration: Additional section for mental health status when required for specific purposes (e.g., employment, insurance)
3. Disability Declaration: Section for declaring any disabilities or special needs, included when relevant for accommodation purposes
4. Pregnancy Status: For female declarants when relevant to medical treatment or employment purposes
5. Travel History: Recent travel history section, particularly important during public health emergencies
6. Occupational Health Risks: Section for declaring work-related health risks, included for employment-related medical declarations
1. Schedule A - Medical Test Results: Attachment for recent medical test results and laboratory reports
2. Schedule B - Vaccination Records: Documentation of vaccination history and immunization records
3. Schedule C - Previous Medical Certificates: Copies of relevant previous medical certificates or clearances
4. Schedule D - Supporting Medical Documentation: Any additional medical records or documentation supporting declarations made in the form
5. Appendix 1 - Terms and Definitions: Glossary of medical terms used in the form for reference
6. Appendix 2 - Privacy Policy Statement: Detailed explanation of how medical information will be handled and protected
Relevant legal definitions
Clauses
Relevant Industries
Healthcare
Education
Insurance
Manufacturing
Construction
Transportation
Hospitality
Aviation
Maritime
Mining
Food Service
Retail
Professional Services
Government
Sports and Recreation
Relevant Teams
Human Resources
Occupational Health and Safety
Compliance and Legal
Risk Management
Medical Services
Employee Relations
Recruitment
Insurance and Benefits
Health Administration
Corporate Medical Services
Relevant Roles
Human Resources Manager
Occupational Health Officer
Compliance Officer
Risk Management Specialist
Safety Officer
Medical Director
School Nurse
Company Doctor
Insurance Underwriter
Healthcare Administrator
Employment Manager
Recruitment Specialist
Corporate Medical Officer
Health and Safety Coordinator
Medical Records Officer
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