MEDICAL CERTIFICATE

(as requested for the obtention of a temporary stay permit in Belgium)

I, the undersigned, , doctor in medicine,

after having performed the following examinations :

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.